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•► <br />TANK CLOSURE CERTIFICATION FORM <br />� o< <br />SUEINEW NAME <br />CIT 61:57� 4cy — FEIL <br />C�ofcK FtzEC�F . <br />GACIIITY lD Y + <br />SITE ADDRESS <br />DA <br />aUSINESS CITU C <br />toe <br />aUSINE55 LP .y/ 106 <br />TANK OWNER NAME <br />car 6 c <br />TANK OWNER ADMESS <br />TANK OWNER CITY <br />-}cy11 <br />5@ STATE SD] DP SDA <br />c.9 ys 37(v <br />TANK rdM1PkAAT1QN <br />Tank # Flammable Vapor Oxygen <br />(State Tank IDA, if applicable) Top <br />Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III r.FRTIFIrATinN <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 <br />STATUS OR AFFILIATION OF CERTIFYING PERSON sas <br />Certifier is a representative of the CUPAILIA: YES ❑ NO)� <br />Name of CUPA/LIA <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />CERTIFIER NAME (PRINT) sae 11 <br />CERTIFIER TITLE s i <br />ADORESS <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />• <br />CSLB licensed contractor (with hazardous substance certificate) <br />Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes, the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Certifiers tank management inatrucdons for scrap dealer. disposal facility, etc: Do <br />NeT C V r i RrV k Wj:rNOyT res rrn16 <br />ris AJ5S. 0'#L C4,411111 Ds 77C1144E 14110-72 CA[s <br />a O O <br />A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />