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TANK CLOSURE CERTIFICATION FORM <br />� x <br />I11Y InE=N71FI('A-11nN <br />i3USINESS VAMC S I FACIUTY 10 s t <br />SITE CCRESS � <br />3USINESS CITY 105 i 3USINESS—'P 106 <br />I <br />I`rANK GAMER NAME 500 <br />TANK CWNER ACCRESS S01 <br />I 7AI4XCWNERCITY 502 STATE 501 i .3P 504 <br />II TANK Q QSi IRF INFORMA71ON <br />Tanks Flammable Vaoor Oxygen <br />(State Tank !Ort. if applicable) Top Canter 9ortom Top Canter Bottom <br />Tank !ntenor <br />Atmosphere <br />Readings <br />III CFETIFICATION <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin, laky residual of tank contents), nnseate and aeons. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />I STATUS OR AFFILIATION OF CERTIFYING PERSCN 505 ! <br />Certifier is a representative of the CUPAiUA. YES ❑ NO ❑ <br />CERTIFIER NAME (PRINK 5m <br />CERTIFIER TITLE 507 <br />Name of CUPAILIA <br />It certifier is other than CUPA/UA cttedt appropriate bar below: <br />Q Certified trttitutrtal tiygienrst (CIH) <br />Certified Safety Professional (CSA) <br />❑ Certi <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soa <br />CERTIFICATION 71ME <br />❑ Certified Mame Cttemrst (CMq <br />Q Registered Environmental Health Specialist (REHS) <br />Q Professional Engineer (Pq <br />❑ Cass II Registered Environmental Assessor <br />Q CSLB licensed contractor (with hazardous substance certificate) <br />C1 Yes E: No This tank previously held flammable or combustible materials. <br />If yes, the tank interior atmosphere shad be re-Ctecsced with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Cartifiers tank management instructions for strap dealer, disposal facility, etc <br />A copy of this certificate shalt accompany the tank to the recydingiamposal facility. <br />