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TANK CLOSURE CERTIFICATION FORM <br /> s FAciuTv to= t <br /> BUSINESS NAME <br /> Pacifi ,o+ <br /> SrE AOORESS <br /> 10 East 12th Street <br /> ,OS BUSINESS ZIP 106 <br /> BUSINESS CITY <br /> 500 <br /> TANK CWNER NAME <br /> ' Pacific Bell 501 <br /> i TANK OWNEA AOORESS <br /> 2600 Camino Ramon, Room 3E000K <br /> STAT <br /> TANK OWNER CITY 502 E S07 IIP SGA <br /> San Ramon11 TANK rtQSLfR-E1NF <br /> CA 14 <br /> Tank S Flammable Vapor Oxygen <br /> (State Tank IDA.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior I <br /> Atmosphere <br /> Readings <br /> 'it CERTIEIrATInNI <br /> On examination of the tank.I certify the tank is visually free from product,sludge.scale(titin,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 /> I <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON SEs <br /> CERTIFIER NAME(PRINT) sae Certifier is a representative of the CUPA/LIA YES C3NO Q <br /> CERTIFIER TITLE sol Name of CUPAA-IA <br /> ADDRESS If certifier is other than CUPAIUA check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sos CERTIFICATIONTIME ❑ Certified Safety Professional(CSP) <br /> Q Certified Marine Chemist(CLIC) <br /> ❑ Registered Environmental Health Specialist(RFHS) <br /> ❑ Professional Engineer(PE) <br /> Q Class Il Registered Environmental Assessor <br /> ❑ CSLB licensed conuactor(with hazardous substance certificate) <br /> This tank previously heli flammable or combustible materials. if yes,the tank interior atmosphere shall be re-checked with a combustib <br /> C3 Yes [2 No le gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management instructions for soap dealer,disposal facility,etc <br /> t <br /> l A copy of this certificate shalt accompany the tank to the recgdmgidisposal facility. <br />