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TANK CLOSURE CERTIFICATION FORM <br />If TANK CI QS1 IRF INFORMATION <br />BUSINESS NAME 1 FACIUTY ID • 1 <br />SITE ADDRESS 104 <br />4� 3z <br />BUSINESS CITY 105 <br />(/ <br />BUSINESS ZlP 709 <br />TANK OWNER NAME/ 5W <br />wP�57- <br />TANK OWNER ADDRESS 501 <br />;o, <br />TANK OWNER CiT*Y502 <br />STATE 503 � IIP � SW <br />If TANK CI QS1 IRF INFORMATION <br />Tank * <br />(State Tank 10#. if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Canter <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />CERTIFIER TITLE 507 <br />Name of CUPA/L1A <br />If certifier is other than CUPA/LlA check appropriate box below: <br />ElPHONE Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />DATE CERTIFIED 5o9 <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />i <br />❑ Class 11 Registered Environmental Assessor <br />1 <br />III CE-211EICATION <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 />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) 506 <br />CERTIFIER TITLE 507 <br />Name of CUPA/L1A <br />If certifier is other than CUPA/LlA check appropriate box below: <br />ElPHONE Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />DATE CERTIFIED 5o9 <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. <br />If yes, the tank interior atmosphere shall be re-checKed with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Cenifier's tank management instructions for soap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />