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11 <br />auSINESS NAME <br />�i�e� con Ste' 323'2- <br />317E A00RESS <br />t ' <br />woo <br />oo <br />' kNK OWNEN NANIC <br />u 7 A NK OWNER AOORESS <br />_ <br />P. Ca • 60g oU�i <br />-.INK OWNER <br />/CITY PAM <br />r <br />Tank # <br />(State Tank 10#, if applicable) <br />`anK Interior <br />rlmosphere <br />?aadings <br />TANK CLOSURE CERTIFICATION FORM <br />s FACILITY 10 0 <br />I <br />allSIHM 23P 105 <br />500 <br />i <br />$a; <br />i <br />502 STATE 509 IIP <br />Top Center Bottom Top Center <br />III CESTISCAMON <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 />,nat the information provided ' is true andAaccurate to the best of my knowledge. <br />CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING P-,RSON $05 <br />CERTIFIER NAME (PRINT) sae Certifier is a representative of the CUPA/UA: YES ❑ NO <br />CERTIFIER TITLE soy n Name of CUPA/L!A <br />AOORESS t" e_ P if centrw is other than CUPA/UA check appropriate box below: <br />CITY ❑ Certified Industrial Hygienist (CIH) <br />PHONE —Ct ) 0 ❑ Carolled Safety Professional (CSP) <br />DATE CERTIFIED sae CERTIFICATION TIME <br />❑ Cartilied Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />i <br />❑ Professional Engineer (PE) <br />❑ Class lI Registered Environmental Assessor <br />CSLB licensed Contractor (with hazardous substance certificate) <br />Yes [T No This tank previously held flammable of combustible materials. If yes. the tank interior atmosphere shad with with a cornbustibie gas !, <br />indicator prior to work being aorulucted on the tank. <br />Canifier's tank management instructions for scrap dealer, disposal facility, eta <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />