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TANK CLOSURE CERTIFICATION FORM <br />pa" Of <br />Tank 0 <br />(State Tank IDS. if applicable) <br />Tank Interior <br />Atmosphere <br />Readings <br />BUSINESS NAME C� �o ` �^. C� y t— kA � f 3 <br />1 <br />w v V <br />FACIUTV IDs t <br />SITE ADDRESS <br />P- , 104 <br />'rte � /� VD <br />BUSINESS CITY GJ ( r �� e—^„) ^ 106 <br />"V I � ' <br />BUSINESS ZIP r� X106 <br />sm <br />TANK OWNER NAME <br />TANK OWNER ADDRESS � � � � � � � � � ��( ('� � A 501 <br />TANK OWNER CITY � ��. �. 502 <br />ST(��503 <br />Zl�y��� � 504 <br />Tank 0 <br />(State Tank IDS. if applicable) <br />Tank Interior <br />Atmosphere <br />Readings <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <br />le <br />CERTIFIER SIGNATURE ( <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />CERTIFIER NAME (PRINT) sm C., <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER TITLE so V\ e ,yY /' <br />` <br />Name of CUPA/LIA <br />ADDRESS NA \ Vl S 3 C <br />If certifier is other than CUPAILIA check appropriate box below: <br />CITY t' \ L•' t_C7 C fl1 <br />❑ Certified Industrial Hygienist (CIH) <br />PHONE CI 4 <br />® Certified Safety Professional (CSP) <br />DATE CERTIFIED sob CERTIFICATION TIME <br />❑ <br />Certified Marine Chemist (CMG) <br />❑ Registered Environmental Health Specialist (REHS) <br />III rFRTIFIrATION <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 f y knowledge. <br />le <br />CERTIFIER SIGNATURE ( <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />CERTIFIER NAME (PRINT) sm C., <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER TITLE so V\ e ,yY /' <br />` <br />Name of CUPA/LIA <br />ADDRESS NA \ Vl S 3 C <br />If certifier is other than CUPAILIA check appropriate box below: <br />CITY t' \ L•' t_C7 C fl1 <br />❑ Certified Industrial Hygienist (CIH) <br />PHONE CI 4 <br />® Certified Safety Professional (CSP) <br />DATE CERTIFIED sob CERTIFICATION TIME <br />❑ <br />Certified Marine Chemist (CMG) <br />❑ Registered Environmental Health Specialist (REHS) <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. <br />If yes• the tank interior atmosphere shah 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: <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />