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TANK CLOSURE CERTIFICATION FORM <br /> I FAM my nENTIFICATION <br /> BUSINESS NAMC 3 FACILJTY 10 0 1 <br /> SITE ADDRESS 104 <br /> BUSINESS CITY 105 allSINESS LP 106 <br /> TANK OWNER NAME 500 <br /> TANK OWNER ADDRESS i0i <br /> TANK OWNER CITY 502 STATE 503 I ZIP 50+ <br /> Tank;* Flammable Vapor Oxygen <br /> (State Tank ID*,if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III CFERTIFICATION <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 505 1 <br /> CERTIFIER NAME(PRINT) 506 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 5o7 <br /> Name of CUPA/LIA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA check appropriate box below: <br /> CITY <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Manne 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-checiced with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiefs tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />