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TANK CLOSURE CERTIFICATION FORM <br /> aUeixESE xAME A{]i. O /I ���� ] FACtllr'I lea t <br /> srtE ccRess u( • �/ <br /> (zspn <br /> iro o <br /> auxlNESa GTr � <br /> r/ � ro] auslxESx <br /> - rAxK cwNEi xAAte 7 ra <br /> i rAMK CnNER AppRExa ]Or <br /> iANK P�NER dIT'r <br /> ��� Soi STATE sm C K,,. <br /> I5 7 <br /> Tanks S1 let- <br /> Flammable Vapor Oxygen <br /> (State Tank IRs,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Resd:ngs <br /> II CERTIFICATION <br /> On examination of the tank,I cenity the tank is visually free from product.sludge,stale(thin,flaky residual at tank contents),Nn seats and debris. I further tardy <br /> ---------------------------------------------------------F-I <br /> that the information Provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGffl, <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON ;d <br /> !FR Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> Name Of CUPAILIA <br /> If ceNfler is aNar than CUPA/LIA cheek apPraPdate box Debw: <br /> CerdSed Industrial Hygienist(CIH) <br /> ITIME ❑ Cenified Safety Professional(CSP) <br /> ❑ Cettilled Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class It Registered Em mortmemal Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This lank previously,held flammable or combusdble materials. If yes,the tank Interior atmosphere shag be re-checked with a combustible gas <br /> indfc attar prior to work being conducted an the lank. <br /> Cardfiers tank management instructions for scrap dealer,disposal facility,etc: <br /> i <br /> I <br /> I <br /> A copy of this certificate shall accompany the rink to the raryCing/dlxposat facility. <br />