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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME 3 FACIUTY IO s I <br /> SITE ADDRESS 104 <br /> BUSINESS CTY 105 aUSINESS LP 106 <br /> TANK OWNER NAME Six) <br /> TANK OWNER ADDRESS 501 <br /> TANK OWNER CITY 502 STATE SM I IIP 504 <br /> 11 TANK .1 QQ 113E INEORMAIMN <br /> Tank# Flammable Vapor Oxygen <br /> (State Tank 10*, if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rPR-nFIrATI0N <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 debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CERTIFIER NAME(PRINT) 506 Certifier is a representative of the CUPAfUA: YES ❑ NO ❑ <br /> CERTIFIER TITLE SoT <br /> Name of CUPAILIA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA check appropriate box bek>Mr: <br /> CITY <br /> PHONE <br /> IPHONE Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sea CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CLIC) <br /> ❑ Registered Environmental Health Specialist(RFHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed con Tactor(with hazardous substance certificate) <br /> ❑ Yes ❑ No This tank previously heli flammable or combustible materials. It yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management instructions for scrap dealer,disposal faclity,etc: <br /> A copy of this certificate shall accompany the tank to the recyCing/disposal facility. <br />