Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />X—a <br />IV/ <br />ro° <br />31TE ADDRESS <br />:a5 dL`S:trE55IIP lot' <br />BUSINESS CITY <br />500 <br />`ANx GwNER NhraE <br />501 <br />tANK OW, SER �DQRE5S <br />50." ST.tTE 503 I IIP Sod <br />TANK 01 ER CITY <br />[(` <br />1 <br />Tank:t <br />Flammable Vapor Oxygen <br />; op <br />Center Bottom Top Canter € <br />Bottom <br />I I <br />(State Tank SC#, if applicable) <br />Tank interior <br />) <br />Atmcspnere <br />Readings -- <br />Ill f FRT�3�'ATI�P1 <br />on examination of the tank, I certify the tank is visually free from product- sludge. scale <br />(thin. flaky residual of tank contents), rinseate and deCns_ I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />1 <br />505 <br />STATUS OR AFFILIATION OF CERTIFYING PERSON <br />CERTIFIER SIGNATURE <br />Cartifier is a representative of the CUP.AJLIA: YES ❑ NO ❑ <br />Name of CUPAJLIA _ <br />if certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professions{ (CSP) <br />CERTIFIER NAME (PRINT) sae <br />CERTIFSER TITLE Sol <br />rADDRESS <br />CITY <br />PHONE <br />GATE CERTIFIED sea <br />CERTIFiCATICN TIME <br />❑ Certified Manne Chemist (CMC) <br />{� Registered Environmental He -M) Soeciaiist (42Er S) <br />❑ Professional Engineer (PE) <br />C3 Cass 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />This tank previously held flammable or combusaie matenais. <br />if yes- the tank interior atmosphere shah be re-diecked with a combustible gas <br />❑ Yes Cl No <br />indicator prior to work being conducted on the tank. <br />Cartifiet's lank management instructions for scrap dealer, disposal facility, etc: <br />