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TANK CLOSURE CERTIFICATION FORM <br />1 FArlt ITV IQrNTIFIrATI0N <br />BUSINESS ua /�, '•� /r/J /� /),. •/� <br />3 <br />PAOUu Nls <br />ol'a ADDRESS <br />IW <br />6USNaSs city ��• <br />las <br />3USINE33 �c <br />lot <br />TANK OWNER NAME <br />3aa <br />TANK OWNER AOOUISS <br />TANKOW CUY <br />Sea <br />STATe Mc I ZIP <br />SW <br />Tank A <br />Rommeule vapor Oxygen <br />($late Tank IDS, if applicable) <br />Top <br />Center Bottom Top <br />Cemex <br />Hotton <br />d ov S1 ��� �•,� <br />CJ <br />'6 <br />2 0. `( <br />�fI' 8 <br />Tank Interior <br />Atmosphere <br />Rsamngs <br />,p,�. <br />,2Dr <br />I <br />. _ �,t^FK271F�rAT1r]N <br />On examination of the tank. 1 canify, the tank is viavalty Fee from product, sludge, scale (thin, flaky, realdual of tank comernsl, dnseate and debris- <br />I tomer candy <br />that the information provided Heroin i flue and accv to the best of my knowledge. <br />CERTIFIER SIGNATURE0-4� <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />sm <br />CERTIFIER NAME (PRINT) sae p I— ! C—eAl <br />Certifier is a representative of the CUPA/UA: YES ❑ <br />NO ❑ <br />CERTIFIER TITLE sot <br />Name of CUPA/I.IA <br />ADDRESS e <br />Iicermier E diner than CUPPILU oheUt appropriate box Itebw. <br />❑ Certified Induatnal Hygienist (CIH) <br />❑ Caddied Safety Professional (CSP) <br />CITY 5 i4vY05 /P <br />PHONE 4KZ45,., %P <br />DATE CERTIFIED id` <br />CERTIFICATION TIME <br />❑ Caddied Manna Chemist (CNS <br />` <br />❑ Registered Environmental Health Specialist (RtiH5) <br />❑ Professlonal Engineer (PIE) <br />Cr�3Class II Registered Envkonmental Aayeasor <br />3eh —CSLB gcensed COrdractof (wlm hazardous substance certificate) , <br />r,� <br />�tl "es ❑ No This tank PMVIMsy held flammable or Wrnouahble materials. <br />If yes. the tank interior atmosphere shag he re -checked With a combustible gas <br />prior to work being conducted on the tank. <br />Jindicator <br />Centflafs Ismt matsagemem inatrtaWdns for strap dealer, disposal faaliy, etc <br />I <br />A copy of this certificate shag accompany the tank to the recyCingldlsposal facility. <br />