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TANK CLOSURE CERTIFICATION FORM <br />Tl r1r. n-rl�nr <br />BUSINESS NAME <br />PACIUWID• 'I <br />SITE A00RESS <br />104 <br />BUSINESS CITY <br />105 <br />aUSINESS zi t05 <br />TANK OWNER NAME <br />500 <br />TANK OWNER ADDRESS <br />501 <br />TANK OWNER CITU <br />T) <br />502 <br />STATE 507 <br />r]P SW <br />- <br />KED; <br />11 TANK i�l 01;118E fNFQE3WA330N.-.--- <br />Tank # Flammable Vapor Oxygen <br />(State Tank 109, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior I <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 peons. I further certny <br />that the information provided herein is true and accurate to the best of my knowledge. <br />505 <br />CERTIFIER NAME (PRINT) 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER TITLE MIT <br />Name of CUPA/LIA <br />ADDRESS If cerfifier is other than CUPAIUA check appropriate box below: <br />CITY ❑ Certified Industrial Hygienist (CIH) <br />PHONE <br />DATE CERTIFIED sae CERTIFICATION TIME ❑ CertiifieSafety Professional (CSP) <br />[3 Certified <br />Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />❑ CSLB licensed wnoactor (with hazardous substance cerdflmte) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes. the tank interior atmosphere shall be rechecked 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 />I A copy of this certificate shall accompany the tank to the meydingidisposal facility. I <br />