Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />I FCrn ITV n;=x ;:irGTIr)m <br />BUSINESS MA1AE <br />3 <br />7ury to a 1 <br />SITE ACCRESS <br />104 <br />BUSINESS CITY <br />105 aUSu1ESS DP toe <br />TANK COINER NAMF <br />I <br />500 <br />TANK C*MER AOORESS <br />i <br />I <br />501 <br />TANK CNNER CITY <br />SO2 <br />STATE 30.7 IIP SC+ <br />If TANK .1 QSLJE�E <br />jNFQEWAT1nN <br />Tank interior <br />Atmosphere <br />Readings <br />Tanks <br />(State Tank ICs. if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Ctnter <br />Bottom <br />III CERTIFICATioNI <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin, flaky residual of tank contents), rinseate and aeons. I kuther certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />CartilSeris a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPA/UA <br />If certifier is other than CUPA/LtA check appropriate box below: <br />❑ Certified industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CHC) <br />❑ Registered Environmental Health SpeciaUst (RENS) <br />❑ Professional Engineer (PE) <br />❑ Ctass II Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance oertHtcate) <br />CERTIFIER NAME (PRINT) 505 <br />CERTIFIER TITLE sor <br />AOORESS <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />[I Yes C3 No This tank previously held flammable or combustible matenas. If yes. the tank Interior atmosphere shall be re -shacked with a Combustible gas <br />indicator prior to work being conducted on the tank_ <br />Cartiflefs tank management instructions for scrap dealer, disposal facility, etc: <br />I <br />1 <br />I <br />A copy of this certificate shall accompany the tank to the recyding/disposat facility. <br />