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G <br />TANK CLOSURE CERTIFICATION FORM <br />"age of <br />Tank # Flammable Vapor Oxygen <br />(State Tank 1D#. if applicable) I Top Center Bottom Top I Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />I <br />III CERTISCATION <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale <br />BUSINESS NAME <br />3 1 PAC:UTY 10 a .t <br />317E AOORESS` <br />tOa � <br />CERTIFIER NAME (PRINT) sw <br />CERTIFIER TITLE sol <br />dUSINES$ CITY Y® ,fig <br />J ! (..00� ( <br />105 3USINESS DP 06 <br />III g 0 7 <br />TANK -ER NAME <br />;� C'0 <br />500 ! <br />TANK OWNER AOORESS <br />'0i <br />❑ Certified Marine Chemist (CMC) <br />TANK OWNER C; �/ / J <br />�/i /&/ N# <br />Sot I STATE 3 I ZIP 544 <br />Tank # Flammable Vapor Oxygen <br />(State Tank 1D#. if applicable) I Top Center Bottom Top I Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />I <br />III CERTISCATION <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale <br />(thin. flaky residual of tank contents), rinseate and aeons. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 I <br />Certifier is a representative of the CUPAIUA: YES ❑ NO ❑ <br />i <br />Name of CUPA/L1A <br />If certifier is other than CUPA/LIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />CERTIFIER SIGNATURE <br />CERTIFIER NAME (PRINT) sw <br />CERTIFIER TITLE sol <br />ADDRESS <br />CITY <br />PHONE <br />GATE CERTIFIED soa <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. If yes. the tank interior atmosphere shalt be re -checked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Certifier's tank management instructions for scrap dealer, disposal facility, etc: I <br />A copy of this certificate shall accompany the tank to the recyCtng/disposal facility. <br />