Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br /> I FAM MY IDEMMEICA-DON <br /> BUSINESS NAME a' aAMTY 10• , <br /> SITE A00RESS tOa <br /> 01?7D V a <br /> BUSINESS CSTY L-oQ I <br /> 105 auslN P 106 <br /> TANK OWNER NAME s6 <br /> PANK OWNER AOOREW SOt <br /> r®- &K <br /> TANK OWNER CITY � ( 502 ST!fc 503 � ZIPl � 5pa <br /> M1V (//_At <br /> t <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank 10s,if applicable) Top Canter Bottom Top i Canter Bottom <br /> Tank interior 1 <br /> Atmospnere <br /> Readings <br /> 1 <br /> On examination of the tank.1 certify the tank is Asuatty free from product.sludge,scale(thin.Uaky residual of tank contents).rinseate and deans. I twttter certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CITIFYING PERSON ws <br /> CERTIFIER NAME(PRINT) sob Czrifier is a representariswe of the CUPARIA: YES ❑ NO Q <br /> CERTIFIER TITLE sou <br /> Name of CUPAAJA <br /> AOORESS024 if ceruffer is other than CUPAIL!A diedt appropriate box below. <br /> CITY <br /> PHONE �1® ® ❑ t Hygienist(CIH) <br /> DATE CERTIFIED scs CERTIFICATION TIME Q Catilled SailisitY Prtrilessional(CSP) <br /> Q Cardfled Marine Cherrust(Circ) <br /> ❑ Registered Environmental Health Specialist(REriS) <br /> ❑ Praftisswal Engineer(PE) <br /> Q Class 11 RegWered Erwkenmenral Assessor <br /> CSLB 1 (with hazardous substance certificate) <br /> Yes Q No This tank tteld flammable or combustible materials. if yes.the tank interior atmospitens shall be with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartiftefs tank management instructitaiiiis for scrap dealer.disposal facility,stc: <br /> A copy of this cerdfi=e stM accompany the tank to the recyc*Wdisposal facility. <br />