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TANK CLOSURE CERTIFICATION FORM <br /> i� d <br /> aumNESS NAME 3 FACtUTY ro• , <br /> - <br /> WE A00REsS <br /> auSINESS crTY_. ,os wm►,rss 23P roe <br /> s� <br /> TANK OWNER NAME <br /> G ` \ <br /> TANK ONMER AOORESS <br /> S02 STATE epi ZIP 5" <br /> TANK OWNER CITY <br /> L A C <br /> It TA jW( .1 r)lqtjEF <br /> Tank S Flammaole Vapor Oxygen <br /> (State Tank IDS.if applicable) Top Center Bottom TOP Center Bottom <br /> Tank Interior I <br /> Atmosphere <br /> Readings <br /> III rSTMFlr-ATTQNI <br /> On examination of the tank.I certify the tank is visually free from product.skrdge.scale(than.flaky residual of tank come=).nnsaate and oetms. I hrrttter csnt(y <br /> Mat the information provided herein is true and accurate to the best of my knowledge <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON 505CERTIFIER SIGNATURE � <br /> CERTIFIER NAME(PRINT) sod Cartifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sift Name of CUPAAJA <br /> ADDRESS If certifier is other than CUPMLIA&Awx appropriate box be1uw. <br /> CITY ❑ Certified IndusMW Hygienist(all) <br /> PHONE ❑ CwafFed Safety P (CSP) <br /> DATE CERTIFIED sof CERTIFICATION TIME <br /> ❑ Certified Marine Chemta(C.1AC) <br /> ❑ Regist�red Envirorxrterttal He&M Spersakst(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Envirmmental Assessor <br /> ❑ CSLB licensed contractor(wittt hazardous substance mtdcM) <br /> ❑Yes ❑No This tank prevtoushr held flammable or combustible matenals. It yes.the tank interior abr spft m shall be re-c necked with a moble gas <br /> indicator prior to wont being conducted on the tank. <br /> Carmers tanK management instruatons for scrap dealer.disposal fatality,etc <br /> A copy of this certificate shall accompany the tank to the recyc ingldisoosal taatity. <br />