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TANK CLOSURE CERTIFICATION FORM <br />P". a <br />Tank S <br />(State Tank 10#, if applicable) <br />Tank Interior <br />Atmosphere <br />Readings <br />BUSINESS NAME 3 <br />FACILITY 10 0 1 <br />Rm l/ / <br />Bottom <br />SITE AOORESS 104 <br />�)D0 C . ';E�D 7`h' "Z611P <br />BUSINESS CITY 105BUSINESS <br />,I-X7/1ROR 1 <br />ZIP 106 <br />TANK OWNER NAME 500 <br />EF��f S L <br />TANK OWNER AOORESS 501 <br />;W C, <br />TANK OWNER CITY 502 <br />STATE 503 <br />IIP 504 <br />,L 7// o � <br />e/.�l <br />Ss-? -d,7/-o <br />Tank S <br />(State Tank 10#, if applicable) <br />Tank Interior <br />Atmosphere <br />Readings <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />Certifier is a representative of the CUPA/L1A: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) sob <br />CERTIFIER TITLE so? <br />Name of CUPA/LIA <br />If certifier is other than CUPA/UA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />ADDRESS <br />CITY <br />PHONE <br />❑ Certified Safety Professional (CSP) <br />DATE CERTIFIED sea <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />1 <br />Ill CERTIFICATION <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. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />Certifier is a representative of the CUPA/L1A: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) sob <br />CERTIFIER TITLE so? <br />Name of CUPA/LIA <br />If certifier is other than CUPA/UA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />ADDRESS <br />CITY <br />PHONE <br />❑ Certified Safety Professional (CSP) <br />DATE CERTIFIED sea <br />CERTIFICATION TIME <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. <br />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 />Carifier•s tank management instructions for soap dealer, disposal facility, etc <br />A copy of this certificate shall accompany the tank to the recycting/disposai facility. <br />