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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAFAC 3 FAclury IC r <br /> A <br /> +v 1 <br /> SITE .40CRESS ipa <br /> (081 MEAb1Ugt) A-0 F, <br /> ausiNFSS CITY 105 allSINESS 2:P rC8 <br /> 1 <br /> TANK OWNER NAME 500 <br /> U j P� <br /> TA ER A00RESS Sot <br /> TANK OWNER CITY 502. STATE 5503 ZP $0+ <br /> PA C <br /> Tank? Flammable Vapor Oxygen <br /> { (State Tank IO*.if applicable) Top Center Bottom Top Center Bottom <br /> I <br /> Tank Interior <br /> Atmospnere <br /> Reaoings <br /> 1 <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 deans. I further certify <br /> thac the information provided herein is true and aerate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br /> i <br /> CERTIFIER NAME(PRINT) $ae Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERT1RER TITLE 507 <br /> Name of CUPAILIA <br /> ADDRESS <br /> If certifier is other than CUPAJLIA check appropriate box below: <br /> CITY <br /> PHONE - [ICenffied Industrial Hygienist(CIH) <br /> DATE CERTIFIED 5o3 CERTIFICATION TIME C2 Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(GMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> CSLB licensed contractor(with hazardous substance Certificate) <br /> Yes ❑ No This tank previously held flammable or combustible materials. 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 /> Certifiers tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recydingldisposal facility. <br />