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TANK CLOSURE CERTIFICATION FORM <br /> F <br /> 9USnNESS ruNE 3 I PAUCITY ID• , <br /> tM <br /> SITE abbREW <br /> 7 /5- 1,4e> :rH <br /> Wz:; tas dU&NE55.^.P <br /> SINESS � lee <br /> eo <br /> TAW(,'wwER NAME <br /> V <br /> 50, <br /> LANk JM+ER A00RE55 <br /> TANK O'+MER CITY 5@ a ATIE Stip I c1P abA <br /> Tanks Flammable vackr Oxygen <br /> (State Tank IC•S, it applicable) Top Center Bottom Top Canter Bottom <br /> Tank!menor <br /> Atmosphere <br /> Readings <br /> III r <br /> On examination of the tank.I certify,the tank Is visually free from product,sludge.scale tMin,flaky resioual of tank contems).nnuate and aeons. I further canify <br /> that the information provided herein is true and acaarate to t+e best of my knowledge. I <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSCN eos <br /> CERTIFIER NAME(PRINT) ste Carafter is a representative of the CUPA/UA: YES ❑ NO ❑ <br /> CERTIFIER TITLE w7 <br /> Name of CUPAlUA <br /> ADORESS If cemter's other than CUPA/LIA check appropriate box below: <br /> Cm <br /> ❑ Certified Irdustnal Hygienist(C:H) <br /> PHONE <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Camfied Sarin ChemiPmfesst(C. (CSP) <br /> ❑ Certified Menne Chemist(CMC) <br /> ❑ Registered Environmental Healdt Specalist(RFrS) <br /> ❑ Profess gnat Engineer(PE) <br /> ❑ CGau II Registered Environmental Assessor <br /> ❑ CSLB licensed C nllril r(with hazardous substance certificate) <br /> ❑Yes ❑No This tank previously held flammable or Combustible materials. If yes.the=K interior atmosphere snag be re-CtecXeo with a comoustble gas <br /> Indicator on"to work being Conducted an the tank. <br /> Cardfiers tank management instructions for scrap dealer.disposal facility,etc - <br /> A Copy of this certificate shall accompany ate tank to me recyCing/disoosal faaiity. <br /> r <br />