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TANK CLOSURE CERTIFICATION FORM <br /> � x <br /> nFmTIFIrATION <br /> BUSINESS NAME 1 FAGUTV 10 s 7 <br /> r� 7� Lint <br /> SITE A00RESS 104 <br /> BUSINESS CITY slzxx)�p (�f//�N A705 BUSINESS ZIP 700 <br /> TANK OWNER NAME y500 <br /> SamVe <br /> TANK OWNER ACORESS 501 <br /> rJ`^'`V`'z oVrj& <br /> TANK OWNER CITU 502 STATE 503 ZIP 504 <br /> It TANK C1 QSHRE 1 <br /> Tank Flammable Vapor Oxygen <br /> (State Tank IDS,if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rFRTIFIrATION <br /> On examination of the tank.I certify the tank is visually free from product.Sludge.scale(thin,laky 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 CERTIF!ING PERSON sae <br /> CERTIFIER NAME(PRINT) sae Cartifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 507 <br /> Name of CUPAlL1A <br /> ADDRESS <br /> If certifier is other than CUPAIUA check appropriate box below: <br /> CITY <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sae CERTIFICATION TIME ❑ Cartified Safety Professional(CSP) <br /> Q Cartified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RF-iS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Gass 11 Registered Environmental Assessor <br /> Q CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes Q No This tank previously held flammable or combustible matenals. If yes.the tank interior atmosphere shah be re-chedted with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifleirs tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyOng/disposal facility. <br />