COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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.7 TANK CLOSURE CERTIFICATION FORM I FArII ITY nI=XlTIFIrATI0N BUSINESS NAME (State Tank 10#. if applicable) Top Center Bottom Top Center Bottom 3 FACILITY to s 1 SITE ADDRESS 61 104 BUSINESS CITY CERTIFIER TITLE 5o7 105 BUSINESS ZIP 105 TANK OWNER NAME CITY � 500 TANK OWNER AOORESS CERTIFICATION TIME 501 TANK OWNER CITY` ❑ Certified Marine Chemist (CMC) 502 STAT � ' IIP y 504 11 TA 0SHEE INEDEMADON Tank 0 Flammable Vapor Oxygen (State Tank 10#. if applicable) Top Center Bottom Top Center Bottom Tank Interior Atmosphere that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER NAME (PRINT) sca CERTIFIER TITLE 5o7 Readings - — — CITY PHONE DATE CERTIFIED ws CERTIFICATION TIME ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class 11 Registered Environmental Assessor ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously hell flammable or combustible materials. If yes, the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank. III CESTISCATION 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 that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER NAME (PRINT) sca CERTIFIER TITLE 5o7 Name of CUPA/UA If certifier is other than CUPA/LIA check appropriate box below: 13Certified Industrial Hygienist (CIH) ❑ Certified Safety Professional (CSP) ADDRESS CITY PHONE DATE CERTIFIED ws CERTIFICATION TIME ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class 11 Registered Environmental Assessor ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously hell flammable or combustible materials. If yes, the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank. Certifiers tank management instructions for scrap dealer, disposal facility, etc: i I A copy of this certificate shall accompany the tank to the recycting/disposal facility.