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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME. a FACIuTy M• t <br /> w <br /> ,o. <br /> SITE AOORE5S <br /> b 1 D 1 <br /> 9uSiNE5S CITY ..r t.y. -� t ray au5[NESS LQ <br /> �] sm <br /> TANK OWNER NAME <br /> TA9R bWNER AOORESS <br /> 90. <br /> TANK OWNER Ci� 502 STATE 503 af+ <br /> Tank;* Flammable Vapor Oxygen <br /> (State Tank IC*.if applicable) Tap Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> 111 CERTIFICA710N <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 deans. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge- <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON s®s <br /> CERTIFIER NAME(PRINT) soa Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sol <br /> Name of CUPAlLIA <br /> AOCRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> .�— ❑ t:erdfied tndtestrial Hygienist(ClH) <br /> PHCNE <br /> DATE GERTIFiEO Sae CERTIFICATION TIME © Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CWC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II 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 shali 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 recyctingldisposal facility. <br />