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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAVE ( 3 FAGUTV ID• + <br /> PA ii <br /> o• <br /> SITE aD0RE55 <br /> O� G• <br /> BUSINESS dlTv C�Q �D� +OS dU51NE 2 0-7 tD� <br /> TANK CANER NAME J 500 <br /> FTNKW ER ADDRESSW+NER CIN 502 STATE 503 JP SM <br /> To !onl C 52u7 <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank IC*.if applicable) Too Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III ('.FRTIFICATION <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 herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON So-' <br /> CERTIFIER NAME(PRINT) 505 Certifier is a representative of the CUPAAJA: YES ❑ NO ❑ <br /> CERTIFIER TITLE ser <br /> Name of CUPA(LIA <br /> ADDRESS <br /> If certifier is other than CUPAlLIA rriecit appropriate box Debw: <br /> CITY <br /> PHONE ElCertified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sos CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> • ❑ CSLB limned contractor(with hazardous substance certificate) <br /> ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes.the lank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Camfiers tank management instructions;for soap dealer,disposal fain ity,etc - <br /> A copy of this certificate shall accompany the tank to the recyCing/disposal facility. <br />