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TANK CLOSURE CERTIFICATION FORM <br />Tank # IFlammable Vapor Oxygen <br />(State Tank ID#. if applicable) I Top Center Bottom Top Center Bottom <br />Wank Interior <br />4mosphere <br />2eadings <br />III rFRTIFirATlQN <br />)n 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 />JSINESS NAME <br />SYCK 6foe <br />�' <br />�"�AKI�� I <br />3 <br />FACIUTY ID • t <br />r�0:3-71to <br />ATE AOORESS <br />,2,qo. nI main <br />T mac- YYlan �ecc,. Ca, <br />tat <br />JSINESS CITY105 <br />Nlankec c. <br />Cc. , <br />�;tTY <br />aU IN LP 106 <br />saco <br />_ <br />ANK OWNER NAME <br />Ca?'6kn0` <br />CERTIFICATION TIME <br />SW <br />ANK OWNER AOORESS <br />❑ Certified Marine Chemist (CMC) <br />iot <br />. D • ��X 1022 Yyl a n A -eco. <br />4 14 <br />ANK OWNER CITY <br />n anke�� <br />502 <br />3TATE 503 <br />C <br />ZIP 504 <br />Gt 533 <br />Tank # IFlammable Vapor Oxygen <br />(State Tank ID#. if applicable) I Top Center Bottom Top Center Bottom <br />Wank Interior <br />4mosphere <br />2eadings <br />III rFRTIFirATlQN <br />)n 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 />hat the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) s� <br />-ERTIFIER TITLE so? <br />Name of CUPA/LIA <br />If certifier is other than CUPA/UA check appropriate box below: <br />13°HONE Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />�;tTY <br />DATE CERTIFIED sob <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously hell flammable or combustible materials. <br />If yes, the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Cartifier's tank management instructions for scrap dealer. disposal facility, etc <br />I <br />A coov of this certificate shall accompany the tank to the recycing/disposal facility. <br />