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1 TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME 3 FACIUTY ID s 1 <br /> SITE ADDRESS 104 <br /> SUSINESS CITY 105 auSINESS ZIP 106 <br /> TANK OWNER NAME 500 <br /> TANK OWNER ADDRESS 501 <br /> 'AHK OWNER C;TY 502 STATE 503 I IIP 504 <br /> Tank t Flammable Vapor Oxygen <br /> (State Tank IC*.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmospnere <br /> Readings <br /> III CERTIFICATION <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 aeons. 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 PSRSCN 505 <br /> CERTIFIER NAME(PRINT) 5o6 Cartifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 507 <br /> Name of CUPA/UA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA check appropriate box below: <br /> CITY <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> Cl 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-checXed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyciing/disposal facility. <br />