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TANK CLOSURE CERTIFICATION FORM <br /> 1 <br /> BUSINESS NAME 3 FAOUWID• <br /> 7!a Fac i l i+y 1144061 <br /> # 05043 <br /> oA <br /> SITE aDORE35 <br /> 1502 1-1. P-1 Por-a80 <br /> e�9GT+ESS GITY ,05 aUSINE55 ZIP <br /> Kton "1JLtT <br /> sro <br /> TANK OWNER NAME <br /> ircle K Stores Ing• <br /> 5a, <br /> TANK ONMER ADDRESS <br /> PC), Box 57-0a4 <br /> 5@ STATE 500 ZIP SW <br /> TANK OWNER CITY <br /> Phoan i K A-?- 15507Z -284 <br /> Tank f Flammable Vapor Oxygen <br /> (Slate Tank IQa.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior ! L� / s / L, <br /> Atmosphere 1 I .� ✓ ✓ <br /> Readings <br /> 16 i iS <br /> '$3 3 3 3 16 /S i 5 <br /> On exa atlon <br /> of*t k.( it ank is visually free from product.sludge.scale(thin,flaky residual of tank contents),rinseate and debris. I further certify <br /> the at' Mi ` and accurate to the best of my know) e. <br /> ERTIFIER SIGNATURESTATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> CERTIFIER NAME(PRINT) Certifier is a representative of the CUPA/UA: YES ❑ NO ❑ <br /> CERTIFIER TITLE so <br /> � Name of CUPA/LIA <br /> ADDRESS /, v If certifier is other than CUPA/LIA Crede appropriate box below: <br /> CITY f ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> Certified Safety Professional(CSP) <br /> DATE CERTIFIED sae CERTIFICATION TIME ❑ <br /> ❑ Candied Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> Is�Professional Engineer(PE) <br /> ❑ Class It Registered Environmental Assessor <br /> ❑ CSLB licensed coryti(with hazardous substance certificate) <br /> ® Yes ❑No This tank previously held flammable or combustible materials. If yes.the tank interior atinosphene shall be re-checKed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifiers tank management instructions for scrap dealer,disposal facility,etc: - <br /> A copy of this certificate shall accompany the tank to the recyc ing/dieposal facility. <br />