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TANK CLOSURE CERTIFICATION FORM <br /> R6gA a <br /> C <br /> BUSINESS NAME ] RACIlJ1Y 10+_ t <br /> I <br /> SITE AO00.E55 <br /> a <br /> u2 pad S% <br /> BUSINESS +os BUSINESS DR 106 <br /> TANK OWNER NAME / SCO <br /> G <br /> TANK OVRIER ADDRESS Sol <br /> TANKCWNERCIT 502 STATEZi Soa <br /> -5;9 G z <br /> Tank x Flammable Vapor Oxygen <br /> (State Tank 108.if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rFRTIFIrATIQN <br /> On examination of the tank. I certify the tank is visually free from produR sludge.scale(min•flaky residual of tank contents),rinseate and aeons. I further certify <br /> mat the information provided herein is true and accurate to the oest of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos i <br /> CERTIFIER NAME(PRINT) sod Certifier is a representative of the CUPAJLIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE SOT <br /> Name of CUPA/LIA <br /> ADDRESS <br /> CITY If certifier is other man CUPAfL1A Caeca appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(C(H) <br /> DATE CERTIFIED sits CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Manne 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 shall be re-checKed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the reryCing/disposal facility. <br />