Laserfiche WebLink
LOSURE CERTIFICATION FORM <br /> aaq. of <br /> 3 FACIUTY IO s <br /> BUSINESS NAME <br /> 104 <br /> SITE AOORESS <br /> �uL 7o n� <br /> BUSINESS CITY 105 auSINESS MP 106 <br /> TANK OWNER NAME 500 <br /> ` l t=t ' <br /> 501TA K OWNER ADDRESS <br /> 3% 'moo li /� N `�... 4 U►J L >ii ` <br /> TANK OWNER CITY 502 STATE 503 IIP 504 <br /> Tank Flammable Vapor Oxygen <br /> (State Tank ID#,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior I <br /> Atmosphere <br /> Readings <br /> 77 1 1 J <br /> III rF=RTIFIrATinN <br /> On examination of the tank.1 certify the tank is visually free from product,sludge.scale(thin,flaky residual of tank contents),rinseate and debris. 1 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 505 ' <br /> CERTIFIER NAME(PRINT) soe Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sol <br /> Name of CUPA/LIA <br /> ADDRESS <br /> CITY If certifier is other than CUPA/LIA check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This tank previously held flammable or combustible materials. If 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 facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyciing/disposal facility. <br />