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...i •.r <br /> .r TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAMI`E (,y', 3 FACILITY Ib+ t <br /> 7 <br /> I 1 \r� <br /> SITE .00RE55 tpa <br /> BUSINESS CITY 105 aUSINEss LP ` Ica <br /> 'AHK CWNER NAME Soo <br /> U 5 P 1 <br /> rA -"ANER AOORESS 501 <br /> r <br /> �. 'ANK OWN ER CITY S02 s-rATE11 zip <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank 10*.if applicable) Top Center Bottom Top Center Bottom <br /> TanK Intenor <br /> Atmospnere <br /> Readings <br /> 1 <br /> III CFETIFICATION <br /> �+I I <br /> I <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 /> I <br /> chat 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) 50e Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sol <br /> Name of CUPA/LIA <br /> r AOORESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> 13Certified Industrial Hygienist(ClH) <br /> PHONE <br /> DATE CERTIFIED 5oa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> � ❑,/Class II Registered Environmental Assessor <br /> 66 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 /> Certifiers tank management instructlons for scrap dealer,disposal facility,etc: <br /> �+ I <br /> �r <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />