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TANK CLOSURE CERTIFICATION FORM <br /> � d <br /> BUSINESS NAME G FACRJTY 10• I <br /> n 4 <br /> SITE A00RESS tM <br /> 927 A-4Y <br /> SUSINESSCTY Z-00/ C,q. ,ee auslNESS DP95Z U IN <br /> TANK OWNER NAME SGB ��//JL <br /> TANK OWNER AO ESS SOr <br /> 9Z? <br /> TANK OWNER CITY Sc STATE.= DP SW <br /> LoD/ Cl• 9SZfti <br /> 11 TANK !LOSURE.NPOPMAT117W <br /> Tank t Flammable Vapor Oxygen <br /> (State Tank 100,if applicable) Top Center Bottom Top Canter Bottom <br /> TTank Interior <br /> Atmosphere <br /> Readings <br /> I <br /> III CFRTIFIrATIQN <br /> On examination of the tank.1 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 two and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON We <br /> CERTIFIER NAME(PRINT) stis Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sor <br /> Name of CUPAILIA <br /> ADDRESS If certifier is other than CUPAIJA check appropriate box below: <br /> CITY <br /> ❑ Carded Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marne ChemNsl(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Gass It Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance cartificate) <br /> ❑ Yes ❑ No This tank previously halo flammable or combustible materials. If yes,the tank interior atmosphere shag be rechecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cawfiers tank management instructions for scrap dealer.disposal facility,etc: <br /> 1 <br /> A copy of this certificate shall accompany the tank to the recyciing/disposal facility. <br />