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TANK CLOSURE CERTIFICATION FORM <br /> asp. Of <br /> BUSINESS NAME 3 FACIUTI 10 s , <br /> C.• C <br /> SITE ADDRESS (� ,04 <br /> V P ' •c' <br /> BUSINESS CITY C� �Q 105 BUSINESS ZIP '06 <br /> TANK OWNER NAME J SW 95 24:2 <br /> s c e J24160 <br /> TANK OWNER ADDRESS Acbr=)�' <br /> 501 <br /> TANK OWNER CSN 502 STATE 503 DP 504 <br /> 3-roakoij11 TAW 0511SEWEDEMADOW <br /> c q 520 <br /> Tank s Flammable Vapor Oxygen <br /> (State Tank 100.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III CES33FICAMON <br /> On examination of the tank.1 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 STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br /> CERTIFIER NAME(PRINT) sm Certifier is a representative of the CUPA/UA: YES ❑ NO ❑ <br /> CERTIFIER TITLE soy <br /> Name of CUPA/UA <br /> ADDRESS if certfier is other than CUPAtL1A check appropriate box below: <br /> CITY <br /> PHONE13Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED so® CERTIFICATION TIME ® Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemet(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere shalt be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartiflet's tank management instructions for swap dealer,disposal facility,etc <br /> A copy of this certificate shall accompany the tank to the recyaingldisposal facility. <br />