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TANK CLOSURE CERTIFICATION FORM <br /> L <br /> s vAauTY to. 19 PA T b kr <br /> iUSInESa NAVE :� OCk] O/\ Z.57- 1I'3e. <br /> ittE+poRESa <br /> Nor'}'Le�-s�- Cor•�er o� El Doraao <;4-reec- -.Jer A.te . 51eekk,, c <br /> 106 auSiNESa civ tab <br /> CA <br /> SUSINESS CIT' Z O Z <br /> rANNC WruME 1 1 <br /> 5FOGuTO <br /> rAnK CwNEa+OGRESS <br /> y 2.S N. E l 6o« clo S��e <br /> "' 502 SPATE SW ZIP 50+ <br /> 'ANKJ ER CTY `/1C f �O\ <br /> SWCN—I-tir G <br /> -p <br /> Tank a Flammable Vapor Oxygen <br /> (Slate Tank ICa,if applicable) Top Center Bottom Top Canter 30hom <br /> Tank Interior A ay c� Q 01 <br /> 2,0.3 2 G.3 I Z-c�• 3 <br /> Atmosphere -3 4 _d TI � � I o t © O !O <br /> Readings <br /> 39 - o� IS7o4 (�cz D�oI o `�o baa 20-3 12 . 3 zo .3 <br /> On examination of the tank.I certify the tank is visually free from product sludge.scale(thin,laky residual of tank comards),rinseate all deans. I fuller certify <br /> that the informationprovided herein is ttua rate to the best of my knowledge. <br /> CERTIFIER SIGNATURE �o r STATUS OR AFFILIATION OF CERTIFYING PERSON Sas <br /> CERTIFIER NAME(PRINT) Sob O ldor- Cc S}� Certifier is a representative of the CUPP/W: YES Q NO Q <br /> CERTIFIER TITLE scar Name of CUPAIUA <br /> 5.�t saFe(ti O <br /> ADDRESS (s d,_,�1c C.(-. v 4{-r_ fIN If certifier is other than CUPA/UA check appropriate box below: <br /> CITY a-C, ❑ Certified Industrial Hygienist(CIH) <br /> PHONE ow -Z(e of <br /> ❑ Certified Safety P i <br /> DATE CERTIFIED sae CERTIFICATION TIME Cartifled Marine Chemist(CMC) <br /> ❑ Registered Environmental]Health Spedalist(RE^S) <br /> ) Professional Engineer(PEI <br /> ❑ Gess It Registered Environmental Assessor <br /> Q CSUS licensed dontaam(with huaroota substance certilcate) <br /> Yes Q Na This tank previously hell flammable or Combustible materials. If yes.the tank interior atmosphere shall be rechecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management insbuctkms`or soap dealer,disposal facility,etc 1 / <br /> 4.t,PO' <br /> A copy of this Certificate shall accompany the tank to he recryCfngidisposal facility. <br />