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TANK CLOSURE CERTIFICATION FORM <br /> ;.a" — of <br /> BUSINESS NAMC 7IIJTV7* 1 <br /> SITE ADORESS 104 <br /> BUSINESS CITY 105 dUSINE55 LP 106 <br /> TANK CANER NAME 5W <br /> TANK CANER ADDRESS 501 <br /> TANK OWNER CITY 502 STATE 503 AP 504 <br /> II TANK QD.S! <br /> Tank$ Flammable Vapor Oxygen <br /> (State Tank IC*,if applicable) Top Center Bottom Top Canter 3ottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III ('PRTIFI('AT10N <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 PERSCN sos <br /> CERTIFIER NAME(PRINT) sod Cartifier is a representative of the CUPA/LIA_ YES ❑ NO ❑ <br /> CERTIFIER TITLE sol <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 Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II 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 /> Cartifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyCing/disposal facility. <br />