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TANK CLOSURE CERTIFICATION FORM <br /> � a <br /> I RAGUTYIbe + <br /> BUSINESS NAME <br /> M <br /> SITE appRE55 / <br /> A 1W <br /> +os auswEss av +tie <br /> 9USINE'as CITY <br /> No <br /> TANKO F.R NAME <br /> o+ <br /> TAMIL OWNE0.ApdRE55 <br /> Soy sTATE No <br /> av so• <br /> TANK dwMER CITY <br /> Q51 IRE INEDE <br /> Tank R Flammable Vapor Oxygen <br /> (State Tank ICS.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> Ill. (-F=RTIFICATInN <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 STATUS OR AFFILIATION OF CERTIFYING PERSON acts <br /> CERTIFIER NAME(PRINT) sae Certifier is a representative of the CUPAILIA: YES ❑ No ❑ <br /> CERTIFIER TITLE SOT <br /> Name of CUPA/LIA <br /> ADDRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety ChemiProfesst(CMnal C)❑ CertifleA Marine Chemist(CNC) <br /> ❑ Registered Fsvironmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Erwironmental 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 shall be m-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> CartifleYs tank management instructions for scrap dealer.disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />