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TANK CLOSURE CERTIFICATION FORM <br /> P•r• 1 d 1 <br /> a cActux to• + <br /> 9U$INf$5 N1YE <br /> SrtE AGJ1CR533 JJ <br /> / �� t e ( C' , •� 10a au51NE5S zip im <br /> BUa1NEa3 GTY O JL <br /> !0a <br /> TANK CANER NAME <br /> I <br /> TANKCAN <br /> 1 <br /> Sai STATE sol IIP .v <br /> TANK CANER CITY <br /> IL TANK CL0SL1RF-JNFQRMA-nQN <br /> Tank s Flammable Vapor Oxygen <br /> (State Tank 100.if applicable) Top Center Bottum Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rPQTIFIrATIQN <br /> On examination of the tank.I certify the tank is visually free from product.sludge.scale(Nin,flaky residual of tank contents),rinseate and deans. I further centy <br /> that the information provided herein is We and a=rale to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIAT)ON OF CERTIFYING PERSON sce <br /> CERTIFIER NAME(PRINT) sod Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE Ad? <br /> Name of CUPA/UA <br /> ADDRESS <br /> If certlfler is oNer than CUPA/LIA charlr appropriate box below: <br /> CITY <br /> PHONE 13Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sou CERTIFICATION TIME ❑ Cenified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(GNC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class If Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This tank previously hell flammable or combustible materials. If yes.the tank interior atmosphens shaft be re-checed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiefs tank management Instructions for scrap dealer.disposal facility,etc <br /> L A ropy of Ihis certificate shall accompany the tank to the rery0nSidisposal facility. <br />