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TANK CLOSURE CERTIFICATION FORM <br /> �Pos d <br /> Wa1MESa NAME i FAGUTY b• t <br /> WE ADDRESS IDA <br /> Sal/ O/ c S�f'eEl� <br /> BUSINESS aTv 105 aU$IK P � ^ 108 <br /> TANK 07 NAYE 5W V <br /> J� <br /> TANK OVMER ADDRESS SOt <br /> 4 <br /> TAKK OWNER aTv 502 STATE 507 ,7P SM <br /> ,S-tDdj2-fvtiJ C� � <br /> Tank= Flammable Vapor Oxygen <br /> (State Tank 100.if applicable) Top Center Bottom Top Center Bottom <br /> Tank pterion <br /> Atmosphere <br /> Readings <br /> I <br /> III CFR71F;rAT10N <br /> On examination of the tank, I Denify the tank is visually free from produm sluoge.sale(thin,flaky residual of tank CAntems),rinseate and DeOns. I further certify <br /> that the information provided herein is true and accurate to thDest of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sm <br /> CERTIFIER NAME(PRINT) s Cartifier is a representative of the CUPAAIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE w7 `/�O Name of CUPAILIA <br /> ADDRESS LV ff (.V <br /> It certifier a other than CUPA/LIA rlreck appropriate box below: <br /> CITY <br /> [3,,,. � Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Mame Chemist(CMC) <br /> ❑ Registered Enwonmental Health Specialist(R&S) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Errvironmenal Assessor <br /> CSLB ficensed wn rector(with hazardous substance certrfitate) <br /> Yes ❑ No This tank prewousy,held flammable or Combustible materials. If yes.the tank interior almosphere Shall be re-cheCKed with a combustible gas <br /> indiotor Prior to work being conducted on the tank. <br /> Certifiers tank management instructions for soap deaw,disposal taality,etc <br /> A copy of this cemfipte stall accompany the tank to the recyCing/disposal faditty. <br />