Laserfiche WebLink
� s <br /> TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAA1fm 3 i'ACKJI'•r�• • I . <br /> rem <br /> 411E AGGRESS <br /> 105 auSWESS ZhP Ice <br /> SUSIhES3 CITY <br /> No <br /> i TANK CNNEit NAME <br /> 1 <br /> $01 <br /> i tANK C4VN6A AQORESS <br /> 502 STATE SMDP <br /> TANK CNNER CITY <br /> 11 TANK -IQ, 1 RE INEDIR ON <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank IDs,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> I <br /> III CORTIFICATION <br /> I <br /> I <br /> On 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 /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON Ns 1 <br /> CERTIFIER NAME(PRINT) we Certifier is a representative of the CUPA&W YES ❑ NO❑ <br /> CERTIFIER TITLE wT <br /> Name of GUPA/l1A <br /> ADORESS if certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> ❑ Certilie0 Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED we CERTIFICATION TIME ® Certified Safety Professional(CSP) <br /> ❑ Certmed Marine Chemist(C•vIC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class Ii Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with haxarldous substance certificate) <br /> 13 Yea C3 No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shag be re-Checked with a comDusabief9as <br /> indicator prior to work being conducted on tate tank. <br /> Cartiifefs tank management instructions for scrap dealer.disposal facility,eta <br /> i <br /> I <br /> f A copy of this certificate shall accompany the tank to the recyC'ag"Poral facility. -- <br />