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N <br />SITE <br />TANK CLOSURE CERTIFICATION FORM <br />10A <br />BUSINESS C17Y <br />105 <br />allSINFSS ZIP los <br />TANK CwNER NAME <br />500 <br />TANK Q�rMER A00RES5 <br />TANK CwNER CITY <br />501 <br />502 STATE 503 I ZIP 50+ <br />Tank 0 <br />(State Tank IDS. if applicable) <br />Flammable Vapor Oxygen <br />Tap Center Bottom Top <br />Canter <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />i <br />f <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />(thin. flaky residual of tank contents), rinseate and debris. I further certify <br />STATUS OR AFFILIATION OF CERTIFYING PERSON Sas i <br />Cartifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPAJUA <br />If certifier is other than CUPA/LIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />Cl Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (REI-iS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) 506 <br />CERTIFIER TITLE S07 <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sea <br />CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable or combusfibfe materials. <br />indicator prior to work being conducted on the tank. <br />If yes. the tank interior atmosphere shall be re -checked with a combustible gas <br />Cartifier's tank management instructions for scrap dealer. disposal facility. etc: <br />A copy of this certificate shall accompany the tank to the recyc ing/disposal facility. <br />