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TANK CLOSURE CERTIFICATION FORM <br /> Pa" of _ <br /> s FACiUTr 10 s , <br /> BUSINESS NAME <br /> Pa <br /> if ,o+ <br /> SITE A00RESS <br /> 10 East 12th Street <br /> ,as ausiNEss na ,oa <br /> BUSINESS Ctrr 95376 <br /> soo <br /> i TANK OWNER NAME <br /> Pacific Bell <br /> 509 <br /> TANK CwNEA A00RESS <br /> I 2600 Camino Ramon, Room 3E000K <br /> 502 I STATE SM IIP <br /> TANK O'NNER CITY <br /> i0+ <br /> San Ramon CA 4 <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank 10A.if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior I <br /> Atmosphere <br /> Readings <br /> I I <br /> III CERTIFICATION <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 /> I <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON Scs <br /> CERTIFIER SIGNATURE <br /> CERTIFIER NAME(PRINT) 5WCartifier is a representative of the CUPAlUA YES Q NO C2 <br /> CERTIFIER TITLE sol <br /> Name of CUPAlUA <br /> ADDRESS if certifier is other than CUPA/LIA check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> Cartified Safety Professional(CSP) <br /> DATE CERTIFIED Soo CERTIFICATION TIME ❑ <br /> ❑ Certified Marine Chemist(CMQ <br /> ❑ Registered Environmental Health Specialist(RFHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contactor(with hazardous substance certificate) <br /> This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shad be re-checked with a Combustible gas <br /> ❑Yes C2 Na <br /> indicator prior to warts being conducted on the tank. <br /> Cartifier's tank management instructions for soap dealer.disposal facility.etc <br /> A copy of this certificate shall accompany the tank to the retyding/disposal facility. <br />