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TANK CLOSURE CERTIFICATION FORM <br /> a.w a <br /> BUSINESS NAME / <br /> SITE ADDRESS Lis <br /> tea <br /> BUSINESS CITY / �/ p�.r 105 BUSINESS zi � t08 <br /> TANK OWNER NAME <br /> TANK OwMER A000.E55 Sot <br /> TANK OWNER CITY 502 STATE 503 I D0. 50" <br /> 11 TAIQK,-1QqIjPEINE0RMAjjQN <br /> Tank A Flammable Vapor Oxygen <br /> (State Tank IDA,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> Ill C-ERTISCATIOU <br /> On examination of the tank.1 cehe to�s visuglu freom prbduct,sludge.scale(thin,flaky residual of tank contents),rinseate and debris. I further certify <br /> that the information provided It is tm accurat the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br /> CERTIFIER NAME 50e �.�' r— O Certifier is a representative of the CUPA/LIA: YES 13NO 13CERTIFIER TIT So <br /> t 719 rName of CUPAILIA <br /> ADDRESS /. { q ' <br /> CITY dl If certifier is other than CUPAILIA check appropriate box below: <br /> H <br /> O <br /> NE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED Soe CERTIFICATION TIME ❑ Certified SafetyProfessional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> �17es ❑ No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be n5-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 lank to the reryciing/disposal facility. <br />