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TANK CLOSURE CERTIFICATION FORM <br />�qe � <br />t CAr`It 1•Ti/ II'1C>\ITICtr`G1'1f1A1 <br />OU31NESS NAME <br />OA-) N <br />3 <br />rAdUfl Id s t <br />SJTE AOOReSS <br />CERTIFIER NAME (PRINT) sae <br />+oa <br />8USINESS CITY <br />OAQ <br />/ 105 <br />3u S �+ G% Toe <br />TANK o+nadER K*ME <br />Ecl v G <br />AW L e: <br />sao <br />TANK O'A'NFdi ADDRESS <br />PIQ /30 <br />00,:5 0 <br />ia, <br />TANK OwHER CITY <br />�+R1'r.fJ <br />SaZ <br />a'ATE Sm <br />c,9It <br />II� 504 <br />Tank Interior <br />Atmosphere <br />Readings <br />-1ANK <br />Tanks <br />(State Tank tD2• if applicable) <br />CLOSURE INE013 ON <br />Flammable Vapor <br />Oxygen <br />Top Center Bottom <br />Top <br />Center <br />Bottom <br />III CE233SCATION <br />On examination of the tank. I certify the tank is visually free from product, sludge. scale (thin, flaky residual at tank contents), rinseate and deans. I ftuther 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 PSr2SCN sol <br />Certifier is a rapreserItative of the CUPAIUA: YES Q NO Q <br />Name of CUPAJLIA <br />If certifier is other titan CUPAILIA chectt appropriate box below: <br />❑ Cerdfied Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />Certified Marine Chemist (C.%Iq <br />Q Registered Environmental Health Specialist (REHS) <br />Q Professional Engineer (PIE) <br />(� Class If Registered Environmental Assessor <br />Q CSLB licensed contractor (with hazardous suostance canificate) <br />CERTIFIER NAME (PRINT) sae <br />C0MFIER TITLE sor <br />AOORESS 00 L [SE <br />CITY .rg p <br />PHONE =01 r7 <br />OATS CERTIFIED sas <br />CERTIFICATION TIME <br />❑ Yes ® No This tank previously held flammable or Combustible materials, <br />indicator prior to wont being conducted on the tank. <br />it yes• the tank interior atmosphere shad be re -checked with a Combustible gas <br />CartMer's tank management Instrucdans for strap deader, disposal facsi+ty, etc <br />A copy of this Certificate shall accomparty ate tank to the recyclitVdisposal facility. <br />6T 39Cd 80014 H1dIA EEVE89060Z TO:60 000Z/LT/50 <br />