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TANK CLOSURE CERTIFICATION FORM <br />1 <br />11 TANK r <br />Tank x Flammable Vapor Oxygen <br />(Slate Tank CO. if applicable) Topes) Center Bottom Top Canter Bottom <br />nk interior <br />Aatmosphere1 J <br />Readings /O / <br />7 <br />III rF-RTIFIrATION <br />On examination of the tank. I certify is vi odua, sludge. scale <br />(thin. flaky residual of tank contents). nnseate and peons. I fuller certify <br />that the information pmvkded h and a rate the st of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON am <br />Certifier is a represented" of the CUPAnJA: YES ❑ NO <br />CERTIFIER NAME (PRINT) <br />CERTIFIER TITLE sar <br />Contractor <br />Name of CUPAIL.IA <br />If certifier i5 timer than CUPA/UA ateac approonate box below: <br />❑ Certified Industrial Hygienist (CIM) <br />C2 Certified Safety Professional (CSP) <br />ADDRESS OX Jot <br />CITY Lodi, — <br />PHONE (209)368-6175 <br />DATE CERTIFIED spa <br />CERTIFICATION TIME <br />❑ Cartfifed Manne Chemist (CMC) <br />7/24/01 <br />/ /tee t ! c —\ <br />V " — <br />C2 Registered Environmental Health Specalist (RE -S) <br />❑ Professional Engineer (PE; <br />❑ Class 11 Registered Environmental Assessor <br />• <br />CSLS licensed contmaor ;wrm hazardous substance carminate) <br />® ❑ No This tank previously veld flammable or cambusdble materials. <br />If yes. the Lank interior atmosphere snail be re-cnecxed win a mmbusoble gas <br />Yes <br />indicator prior to won being conducted on the tank. <br />Camfiers tank management instructions !or scrap dealer. disposal reality. etc <br />None <br />A copy of this certificate shall accompany the tank to the recytbing/disposal faGiy. <br />