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TANK CLOSURE CERTIFICATION FORM <br />Rpt a <br />aUSINEW NAME <br />] <br />FACRJTV Ib Y t <br />nn ^^ <br />� VAN <br />$ITE/�ADORE55 /1 <br />tw <br />SINE55 CLTy <br />t05 <br />aUSINE55 DP tae <br />TTANNXO/YMER�NA�M/E <br />TANK OWNER ADDRESS <br />alt <br />6?E - <br />TANKOWMERCIN <br />502 <br />STATE 503 <br />DP 50� <br />11 TANK .1 INECIPMATIt"IN <br />Tanks Flammable Vapor Oxygen <br />(State Tank 109, If applicable) Top <br />Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III ('I=RTIFIfATinN <br />On examination of the tank. I certify the tank is visually free from product. sludge, scale (thin, flaky residual of tank contents), nnseate and debris. 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 ws <br />Certifier is a representative of the CUPA/UA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) sod <br />CERTIFIER TITLE 5m <br />Name of CUPA/LIA <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />❑ CSLB licensed contractor (with h=3rdous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes. the tank interior atmosphere shall be re-checKed 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 recyc ing/disposal facility. <br />