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TANK CLOSURE CERTIFICATION FORM <br /> P.9. ar <br /> BUSINESS NAME 3 FAC1l11Y100 <br /> 31TE A00RESS IOA <br /> BUSINESS CRY 105 du5wE55 LP Im <br /> TANK OWNER NAME 100 <br /> I <br /> TANK OWNER A00RESS aO1 <br /> TArvN OWNER CITY 502 STATE 503 IIP i0A <br /> Tank;;l Flammable Vapor Oxygen <br /> (State Tank IOd,if applicable) Top Center Bottom Top Center Sonom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III r.FRTIFIrATION <br /> On examination of the tank, I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and peons. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON scs i <br /> CERTIFIER NAME(PRINT) sod Certifier is a representative of the CUPArUA: YES ❑ NO Q <br /> CERTIFIER TITLE $07 Name of CUPA/UA <br /> ADORES$ If certifier is other than CUPA/LIA check appropriate box below: <br /> CIN ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sm ZCEPTIFITIONE ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RETS) <br /> ❑ Professional Engineer(PEI <br /> ❑ Cta II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) 1 <br /> C1 Yes ❑ No This tank previously held flammable or combustible materials. If yes.the tank interior abnosphem shall be re-check with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyCing/dlsposal facility. <br />