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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS N .0 Svin <br /> la lij <br /> 1 iACI1JTY ID• 1 <br /> c4sofiat <br /> SITE ADORE55 <br /> too <br /> 2 5 a e eT .ST I(To l) RSZo S <br /> BUSINESS CITY G �rN 105 aUSINEss DP 95Z Z35 tpe <br /> TANx DWNER NAME 50p .J J <br /> AeSIWj <br /> o <br /> TANK DNNER ADpREss I $Dt <br /> 2 _ Run CI C <br /> TANK d ER ctn <br /> 502 STATE SOJ DP SDK <br /> 3TO Ci o 11 TANK -.1 QSI IRE INFORMAIJON Q9 52u-7 <br /> Tank A Flammable Vapor Oxygen <br /> (State Tank ICa, d apolicabie) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rFRTIFIrATION <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. 1 huller 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 sox <br /> CERTIFIER NAME(PRINT) sae Certifier is a representative of the CUPAAJk YES ❑ NO ❑ <br /> CERTIFIER TITLE 50T <br /> Name of CUPA/LIA <br /> ADDRESS If certifier is other than CUPA/UA check appropriate oox below: <br /> Cm <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED so; CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RETS) <br /> ❑ Professional Engineer PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere shag be re-checKed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiers tank management instructions for soap dealer.disposal facility,etc <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />