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TANK CLOSURE CERTiFIcATioN FORM <br /> x <br /> e1.18INESS NAME 3 FACtUry los t 7I . <br /> SITE AGGRESS tos <br /> SUSINE53 CITY los ausmN-s zip 106 <br /> i TANK CAINE+2 NMtE <br /> $00 <br /> 1 <br /> i TANKCNNBRAQQRESS 301 <br /> TANK CM+ER CITY <br /> $02 STATE So I rip Si+ <br /> 1051 IRE MEORMANON <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank IDs,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III CESTMICATION <br /> On examination of the tank.I certify the tank is visuaify 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 3"s <br /> CERTIFIER NAME(PRINT) son Canitief is a representative of the CUPA&W YES ❑ NO ❑ <br /> CERTIFIER TITLE w7 <br /> Name of CUPAAJA <br /> ADDRESS If certifier is other than CUPAfLIA check appropriate box below: <br /> CITY Q Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED ser CERTIFICATION TIME Q Certified Safety Professional(CSP) <br /> Q Certified Marine Chemist(GMAC) <br /> Q Registered Environmental Health Specialist(RENS) <br /> Q Professional Engineer(PE) <br /> Q Class If Registered Environmental Assessor <br /> ❑ CSLB Goensed corrnaetor(whit hazardous substance certificate) <br /> 13 Yes ❑No This tank previously held flammable at combustible materials. if yes.the tank kftrior atmosphere shag be ns-Ctec ited with a combustible gas <br /> indicator prior to work beim conducted on the tank. <br /> Catdffer's tank management instructions for scrap deafer.disposal facility,etc: ' <br /> J <br /> i <br /> A copy of this certificate shall accompany the tank to the recycgrWdisposai facility. <br />