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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS HAMS <br /> SITE ACCRESS ICU <br /> 0 . <br /> SUSINESs CITY y A . _ . <br /> (%�'L• t05 2USINE55 LPA E <br /> 7�•7 n' t� <br /> ' <br /> TANK CANER NAMC Or V <br /> l <br /> i TANK CMv£R ADDri£Ss --" <br /> 301 <br /> t2-foUU ( rnIN P— rvif,r4 !Yi aC��G <br /> C11KNC.'MER CITY <br /> 542 STATE 503 I IIP <br /> Tank;* Flammable Vapor <br /> (State Tank ID0,if applicable) Oxygen <br /> Top Center Bottom Top Center Bottom <br /> Atmosphere <br /> Tank p ehere re L D <br /> Readings o <br /> i � q161 <br /> On examination information <br /> of the tank,1 certify the tank is visually lyes from product.slICATION <br /> udge,scale(thin,flaky residual of tank contents),rinseate and debris. 1 further cer,)fy <br /> that the information provided herein is true and aceurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PARSON S S I <br /> CERTIFIER NAME(PRINT) saa <br /> CERTIFIER TITLE SOT Cartifier is a representative of the CUPA/L1A: YES ❑ NO ❑ <br /> ADDRESS <br /> Name of CUPAJUA <br /> CITY If certfier is other than CUPA/LIA check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sca CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REIFiS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class If Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> Cl Yes ❑No This tank previously held flammable or combustible materials. It yes,the tank interior atmosphere shalt be re-checked with a combustible gas <br /> indicator prior to work being Conducted on the tank. <br /> Cartifier's tank management insttuctfons for soap dealer,disposal fdul ty,etc: <br /> 1 <br /> i <br /> I <br /> I <br /> A copy ofthis certificate shall accompany the tank to the recyCing/disposat faolety <br />