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TANK CLOSURE CERTIFICATION FORM <br />Tank # Flammable Vapor Oxygen <br />(State Tank ID#, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III CEPTISCATION <br />I EACH Ely IDEN11FICATIOU <br />BUSINESS NAME <br />/� 3 FACILITY IDS 1 <br />CERTIFIER SIGNATURE <br />SITE ADDRESS <br />10a <br />i ice_Ajo <br />�� <br />QUSINESS CI <br />105 BUSINESS ZIP ' 106 <br />CITY <br />PHONE <br />TANK OWNER NAME <br />500 <br />TANK OWNER A DRESS <br />Sol <br />SA <br />❑ Registered Environmental Health Specialist (RENS) <br />TANK OWNER CITY <br />502 <br />STATE 503 <br />ZIP 504 <br />❑ Class 11 Registered Environmental Assessor <br />Tank # Flammable Vapor Oxygen <br />(State Tank ID#, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />III CEPTISCATION <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 />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON SOS <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) Sob <br />CERTIFIER TITLE 507 <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA check appropriate box below: <br />11Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED Sob <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />if yes, the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Certifier's tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyciingldisposal facility. <br />