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TANK CLOSURE CERTIFICATION FORM ;-a" Of III rI=RTIFIrATIQN Tank Interior Atmosphere Readings Tank # (State Tank ID#, if applicable) BUSINESS NAM Oxygen 3 PACIUTY 10 • t SITE ADDRESS Bottom 104 BUSINESS CITY ADDRESS 105 BUSINESS LP 106 NK OWNER NAME CERTIFICATION TIME e t 500 ❑ Certified Marine Chemist (CMC) ( '1 ilt - ( Vsa TANK 0 ER ADDRESS ❑ Registered Environmental Health Specialist (RENS) 501 ❑ Professional Engineer (PE) TANK OWNER CITY S ❑ Class II Registered Environmental Assessor 502 STATE 503 I IIP 504 C4t �s ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes, the tank interior atmosphere shall be re -checked with a combustible gas Indicator prior to work being conducted on the tank. III rI=RTIFIrATIQN Tank Interior Atmosphere Readings Tank # (State Tank ID#, if applicable) Flammable Vapor Oxygen CERTIFIER SIGNATURE Top Center Bottom Top Center Bottom Name of CUPA/L1A If certifier is other than CUPA/LiA check appropriate box below: ❑ Certified Industrial Hygienist (CIH) ❑ Certified Safety Professional (CSP) ADDRESS CITY PHONE DATE CERTIFIED sob CERTIFICATION TIME ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class II Registered Environmental Assessor III rI=RTIFIrATIQN 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 that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER NAME (PRINT) sob CERTIFIER TITLE soy Name of CUPA/L1A If certifier is other than CUPA/LiA check appropriate box below: ❑ Certified Industrial Hygienist (CIH) ❑ Certified Safety Professional (CSP) ADDRESS CITY PHONE DATE CERTIFIED sob CERTIFICATION TIME ❑ Certified Marine Chemist (CMC) ❑ Registered Environmental Health Specialist (RENS) ❑ Professional Engineer (PE) ❑ Class II Registered Environmental Assessor ❑ CSLB licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes, the tank interior atmosphere shall be re -checked with a combustible gas Indicator prior to work being conducted on the tank. Certifier's tank management instructions for scrap dealer, disposal facility, etc: A copy of this certificate shall accompany the tank to the recyclingidisposal facility.