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TANK CLOSURE CERTIFICATION FORM <br />Tank # Flammable Vapor Oxygen <br />(State Tank IDS, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior I <br />Atmosphere <br />Readings <br />III rFRTIFIrATION <br />BUSINESS NAME <br />3 FACILITY ID • 1 <br />SITE AOORESS <br />104 <br />BUSINESS CITY <br />105 <br />BUSINESS Z1P 106 <br />TANK OWNER NAME <br />$Go <br />TANK OWNER ADDRESS <br />501 <br />TANK OWNER CITY <br />502 <br />STATE 503 I IIP 504 <br />Tank # Flammable Vapor Oxygen <br />(State Tank IDS, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior I <br />Atmosphere <br />Readings <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 of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO Q <br />CERTIFIER NAME (PRINT) sob <br />CERTIFIER TITLE sol <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 />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sob <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RF -HS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />Q CSLB licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously heli flammable or combustible materials. 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 />Certifier's tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recycting/disposal facility. <br />