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TANK CLOSURE CERTIFICATION FORM <br />BUSINESS NAME �f� I ` / /•�/� ` <br />ebi- <br />] <br />FACILITY Ips f <br />SITE ADDRESS <br />SIS `IT � T <br />no• <br />BUSINESS CITY _ - ` <br />LJy�J <br />10 <br />auBlNEss ng2s.�2p fm <br />7 <br />TANK ONMER NAME�''�1}}�-�L�L,,�{',, <br />� <br />TANK OVAMER ADDRESS A` `! <br />J[S �'V� <br />�pf <br />TANK OWNER CITY[/}�/` ` I <br />VCA.r1W/�/ <br />503 <br />STATE IKO <br />•� <br />`A <br />SOf <br />(MR <br />9S -3-,c <br />Tank a Flammable Vapor Oxygen <br />(State Tank IDC, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III rFRTIFfrATIQN <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 CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPA/LIA <br />If certifier is other than CUPA/UA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Candied 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 licensed Contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) Six; <br />CERTIFIER TITLE sn, <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sue <br />CERTIFICATION TIME <br />• <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />indicator prior to work being conducted on the tank. <br />If yes• the tank interior atmosphere shall be re -checked with a combustible gas <br />Certifier's tank management instructions for scrap dealer, disposal facitty, etc: <br />A copy of this certificate shall accompany the tank to the recyc ing/disposal facility. <br />