COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

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TANK CLOSURE CERTIFICATION FORM ?age _ of _ Tank a1 Flammable Vapor Oxy (State Tank 10*. if applicable) t Top Center Bottom Top Center Tank Interior Atmosphere Readings On examination of the tank, 1 certify the tank is visually free from product. sludge. scale (thin, flaky residual of tank contents), rinseate and debris. I further cert' fy that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON scs CERTIFIER NAME (PRINT) soe Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER TITLE sol Name of CUPA/L!A ADDRESS If Certifier is other than CUPA/UA check appropriate box below: CITY ❑ Certified Industrial Hygienist (CIH) PHONE DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional (CSP) ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class 11 Registered Environmental Assessor ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes. the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank. Certtfier's tank management instructions for scrap dealer, disposal facility, etc: A copy of this certificate shall accompany the tank to the recyCing/disposal 3 PACIUTY t0 s 1 BUSINESS NAME 104 SITE ADORESS - 105 BUSINESS LP 106 BUSINESS CITY 50o TANK OWNER NAME I 501 TANK OWNER ADORESS 502 STATE 503 IIP 504 TANK OWNER CITY I Tank a1 Flammable Vapor Oxy (State Tank 10*. if applicable) t Top Center Bottom Top Center Tank Interior Atmosphere Readings On examination of the tank, 1 certify the tank is visually free from product. sludge. scale (thin, flaky residual of tank contents), rinseate and debris. I further cert' fy that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON scs CERTIFIER NAME (PRINT) soe Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER TITLE sol Name of CUPA/L!A ADDRESS If Certifier is other than CUPA/UA check appropriate box below: CITY ❑ Certified Industrial Hygienist (CIH) PHONE DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional (CSP) ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class 11 Registered Environmental Assessor ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes. the tank interior atmosphere shall be re -checked with a combustible gas indicator prior to work being conducted on the tank. Certtfier's tank management instructions for scrap dealer, disposal facility, etc: A copy of this certificate shall accompany the tank to the recyCing/disposal