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TANK CLOSURE CERTIFICATION FORM <br /> s FACIUWIo. , <br /> 9USINESS NAME <br /> C!A�11 Ty inFNTIFIrATION <br /> TI e G�iv�s ,a <br /> ST ADDRESS <br /> 42'I l3 /L O/•4�/0.�D tt.Ai <br /> t05 aU51NE55 LPQ <br /> BUSINESS kiltCA• �, 7 <br /> TANK O ER NAME <br /> TANK OWNER ADD ESs <br /> SDi SPATE !0] ZIP 50� <br /> TANK OWNER CITY <br /> C-4 <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank IDS,if applicable) Top Center Bottom Top Center Sodom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III CE TWIrATION <br /> On examination of the tank.1 caeify the tank is visually free from product.sludge.scale(thin.flaky residual of tank contents).rinseate and debris. I further czrtify <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 ws <br /> CERTIFIER NAME(PRINT) soe Cartifler is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE wT <br /> Name of CUPA/LUl <br /> ADDRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sm CERTIFICATION TIME ❑ Cemfied Safety Professional(CSP) <br /> ❑ Certified Marne Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Gass II Registered Environmental Assessor <br /> ❑ CSLB licensed Contractor(with hazardous substance CertMrate) <br /> 11 Yes [3 No This tank previously held flammable or combustible materials. 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 /> Cartiflers tank management instructlens for scrap dealer.disposal facility,etc <br /> A copy of this certificate shall accompany the tank to the recycing/disposal facility. <br />