Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />Page _ of <br />I. FACILITY IDENTIFICATION <br />BUSINESS NAME 3 <br />=ACILITY ID # 1 <br />Flammable Vapor <br />Oxygen <br />SITE ADDRESS 104 <br />Top Center Bottom Top <br />BUSINESS CITY - 105 BUSINESS ZIP 108 <br />� <br />CQ <br />rpC`L i i� <br />ANK OWNER NAME 500 <br />L C <br />TANK OWNER ADDRESS 501 <br />C;) � <br />TANK OWNER CITY 502 <br />STATE 503 <br />ZIP 504 <br />PHONE <br />DATE CERTIFIED so8 <br />CERTIFICATION TIME <br />�� <br />7/7/i(/ <br />B �z/�� �� D� <br />�^ <br />❑ Certified Marine Chemist (CMC) <br />11 TANK QI0,qIIRF INFORMATION <br />Tank Interior] <br />Atmosphere <br />Readings <br />Tank # <br />(State Tank ID#, if applicable) <br />Flammable Vapor <br />Oxygen <br />CERTIFIER SIGNATURE J, <br />Top Center Bottom Top <br />Center <br />Bottom <br />CERTIFIER TITL s /� 1 <br />, <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA check appropriate box below: <br />% <br />, hC .j)— <br />❑ Certified Industrial Hygienist (CIH) <br />LJ Certified Safety Professional (CSP) <br />PHONE <br />DATE CERTIFIED so8 <br />CERTIFICATION TIME <br />�� <br />7/7/i(/ <br />B �z/�� �� D� <br />�^ <br />❑ Certified Marine Chemist (CMC) <br />i <br />y/ <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />Class II Registered Environmental Assessor <br />III ('PIRTIFICATioN <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 herei t e and acoelrate o thre best of my knowledge. <br />CERTIFIER SIGNATURE J, <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br />CERTIFIER NAME (PRINT)'ev <br />Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br />CERTIFIER TITL s /� 1 <br />, <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA check appropriate box below: <br />ADDRESS <br />CITY <br />, hC .j)— <br />❑ Certified Industrial Hygienist (CIH) <br />LJ Certified Safety Professional (CSP) <br />PHONE <br />DATE CERTIFIED so8 <br />CERTIFICATION TIME <br />�� <br />7/7/i(/ <br />B �z/�� �� D� <br />�^ <br />❑ Certified Marine Chemist (CMC) <br />i <br />y/ <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />Class II Registered Environmental Assessor <br />,❑,/ <br />IJ' 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 />Certifier's tank management instructions for scrap dealer, disposal facility, etc: <br />-✓ <br />A' <br />bit-Jcl•"l1crcZ � 01011w'� c4l"" <br />/�i"� ��► L a5 g�,ao� G� <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />DTSC 1249 (4=;:) (8/98) <br />