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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAMC ���"'� Q�' oL /L 3 FAclu"10+ <br /> SITE 40ORESS 1tM <br /> BUSINESS CITY / 105 BUSINESS DP !OO <br /> � G <br /> TANK CwNER NAME <br /> Y — <br /> TANK CWNERA RESS , A-(:�O N S01 <br /> V <br /> TANK CWNER CITv �n w W2 3T I IIP 504 <br /> 11 JAN -1 QS1 IRE INEORMADQN- <br /> Tank A Flammable Vapor Oxygen <br /> (State Tank ICA.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere � <br /> ReadingsIII rFRTIFICATION <br /> ` <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 /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> CERTIFIER NAME(PRINT) see Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE so? <br /> Name of CUPA/UA <br /> ADDRESS If certifier is other than CUPA/L1A check appropriate box below: <br /> CITY <br /> ElCertified Industrial Hygienist(C)H) <br /> PHONE <br /> DATE CERTIFIED sos 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. It yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiefs tank management instructions for scrap dealer.disposal fatality,etc: <br /> i <br /> A copy of this certificate Shall accompany the tank to the recyCingldisoosal facility. <br />