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e <br /> TANK CLOSURE CERTIFICATION FORM <br /> BUSWESS NAME 3 FAC9JrY a• , . <br /> 10+ <br /> srM AccR<_ss . <br /> ,os auSINFSS Z1® toe <br /> eUSiNE33 crrY <br /> 309 <br /> i TANK CNNbit NAME <br /> 1 <br /> 307 <br /> TANK vwMEA AOORESS <br /> TANK C+YNER CItY SQL STATE Sol � LP sc+' <br /> All N <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank IQs,if appecab+ei Yop Center Bottom Top Cerner 80liom <br /> Tank Interior <br /> Atmosphere <br /> Readings 1 <br /> i I <br /> I <br /> On examination of the tank•i cenity,the tank is visually free from product.sludge.scale(thin.flaky residual of tank contents),rinseate and debris. 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 PcR$ON <br /> CERTIFIER NAME(PRINT) w9 Cant fer is a representative of the CUPANA: YES ❑ NO ❑ i <br /> CERTIFIER TITLE SOT t <br /> Name of CUPA/L!A <br /> ADORESS If cenifier is other than CUPAJLIA check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED mCERTiFtCATION TIME ® Certified Safety Prolessanal(CSP) <br /> ❑ Certified Marine Chemist(C-MC) <br /> ❑ Registered Environmental Health Specialist(REi•IS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class If Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> [3 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 /> abdicator prior m work being conducted on the tank. <br /> Cartifier's tank management ktstrucdo ns for scrap dealer,disposal facility,etc <br /> I <br /> L A copy of this certificate shall accompany the tank to the keoychng"posat facility.- <br />