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TANK CLOSURE CERTIFICATION FORM <br />-in* <br />of <br />Tank Interior <br />Atmosphere <br />Readings <br />BUSINESS NAME �$ d ®� /y pyn p 3 FACIUTY 10 ° 1 <br />S/7C L 4 irYy rr o /W reg G L`" /\ Iii <br />SSITE ADORESS t0a <br />Y/c®lz <br />BUSINESS CITY 16049/ 105 <br />BUSINESS LIP t08 <br />TANK OWNER NAME 500 <br />if(? aleaAl wr7 en <br />TANK OWNER ADOREsSSS 501 <br />y� <br />TANK OWNER CITY 502 <br />I STATE 503 I ZIP 504 <br />Tank Interior <br />Atmosphere <br />Readings <br />11 TANK <br />Tank s <br />(State Tank I09, if applicable) <br />.1 QQ IPE INFORMOM <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <br />III CERTIFIrATIC)N1 <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 deans. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSCN 5cs <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPA/UA <br />If certifier is other than CUPA/below:A check appropriate box below: <br />13Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (REIMS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />if yes. the tank interior atmosphere shall be re -checked with a combustible gas <br />CERTIFIER NAME (PRINT) sod <br />CERTIFIER TITLE Sol <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED soa <br />CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable or Combustible matenals. <br />indicator prior to work being conducted on the tank. <br />Certifier's tank management instructions for swap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyCing/disposal facility. <br />