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TANK CLOSURE CERTIFICATION FORM <br />BUSINESS NAME <br />SITE ADDRESS <br />2qta5 <br />aU&NESS EIP 1pe <br />TANkONRIER NAME <br />M <br />500 <br />TANK O'MrER ADORESS <br />zr�i tJa v 1a►� , <br />�t <br />TANK ONaaN..ER/CITY <br />TUVIL1 <br />zax ;r•rE ws <br />civ / so. <br />�r ]7�L <br />Tank x <br />(Slate Tank IDE. if applicable) <br />Flammable Vapor Oxygen <br />Tao Center 30ttom Tap <br />Center <br />3ottom <br />Tank Interior <br />Atmosphere <br />Readings <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 debris. I further mrtify <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 spe <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO Q .. <br />Name of CUPA/L1A <br />If certifier is other than CUPAIUA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safely Professional (CSP) <br />Q CertifkW Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RFHS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />Q CSLB licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) 506 <br />CERTIFIER TITLE sm <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable or combusdble materials. If yes. the tank interior abnosphere shag be le-rnecked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Certifiers tank management instructions for scrap dealer. disposal facility, etc <br />A copy of this certificate shall accompany the tank to the mcyding/disposal faaity. <br />