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TANK CLOSURE CERTIFICATION FORM <br /> USINEw NAME QQ 3 FACIUtY in 1 <br /> � �v <br /> ITE AabRESS 1M <br /> SmEw LP IW <br /> O'NESS CITU ` <br /> ANNO ERNAME 1V 5(XI <br /> ANK CWNER ADDRESS a01 <br /> ANK OWNER Citt 501 STATE !o] aP 561 <br /> Tank At Flammanle Vapor oxygen <br /> (State Tank IDC, if applicable) Top Center Bottom Top Canter Bottom <br /> 'ank Interior <br /> dmosphere <br /> :Catlings <br /> " I 1`17IRTIFICATION <br /> )n examination of the tank. I certify the tank is visually free from product, sludge. scale (thin, flaky residual of tank contents), rinseate and debris. I further certify <br /> hat the information provided herein is true and accurate to the best of my knowledge. <br /> :ERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> :ERTIFIER NAME (PRINT) sos Cartifier is a representative of the CUPA&IA: YES ❑ NO ❑ <br /> :ERTIFIER TITLE soT <br /> Name of CUPA/LIA <br /> >ODRESS <br /> It certifier is other than CUPA/LtA. check appropriate box below: <br /> 'ITM ❑ Certified Industrial Hygienist (CIH) <br /> 'HONE <br /> 13 Certified Sarin Professional (CSP) <br /> DATE CERTIFIED sae CERTIFICATION TIME <br /> ❑ Certified Monne Chemist (CMC) <br /> ❑ Registered Environmental Health Specialist (RENS) <br /> ❑ Professional Engineer (PE) <br /> ❑ Claw 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 shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifier's tank management instructions for scrap dealer, disposal facility, etc: <br /> I <br /> A copy of this certificate shall accompany the tank to the recyc!ing/disposal facility. <br /> i <br /> I <br /> I - <br />