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NP <br /> TANK CLOSURE CERTIFICATION FORM <br /> a,9. or <br /> BUSINESS NAME t,YtFI-6 5��-"t� �N��`' 3 FACIUTY IO t <br /> 3�-A4 J 89 <br /> SITE AOORES3 tOA <br /> 7 <br /> BUSINESS CITY 105 3USINESS ZIP 10e <br /> TANK CwNER NAME 1 •1/^ w A..t SOO <br /> TANK--'AVER ACIORESS ASO N 501 <br /> ® � t <br /> TANK C'NNER CITY �n^� �, w 502 STA I DP SOS <br /> Tank At Flammable Vapor Oxygen <br /> (Slate Tank IDIx.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere — �� <br /> Reaoings <br /> III CESDIFICATION <br /> On examination of the tank,1 cenity 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) sos Cartifier is a representative of the CUPA/UA: YES ❑ NO ❑ <br /> CERTIFIER TITLE soT <br /> Name of CUPA/LIA <br /> ADDRESS If certifier is other than CUPA/UA check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soa CERTIFICATION TIME ® Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(C.MC) <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 rechecked with a combustible gas <br /> Indicator prior to work being conducted on the tank. <br /> Cartilier's tank management instructions for soap dealer,disposal fatality,ate: <br /> A copy of this certificate shall accompany the tank to the recyCingtdisoosal facility. <br />