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TANK CLOSURE CERTIFICATION FORM <br /> eusxess /,� <br /> SME,cceess/w`f�l- <br /> t•� ,IL /F-1 JV/Cyw)L Y <br /> ra. <br /> 83�n Cen��/ Ade- <br /> 9uElxEas pTY �n /1 •�/� cos dualNEa6L �J ,pp <br /> TANN CANfJr IHNcif 1+4 <br /> 1 <br /> TANN Cv.NFeR wDOREE3 � bl <br /> rj r QC r�C� <br /> TAhx CIw1ER CITY 502 aT�Ta sm m K+' <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank IOa,if applicable) Top Center Bottom TOP Center BtMT. <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rj=RTIFIrATlf')N <br /> On examination of the tank.I Canity the tank is visually free from product.sludge,wale(Nin.flaky residual of tank contents),rinseate and debris. I further cently <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 <br /> CERTIFIER NAME(PRINT) sue Cardfier is a representative of the CIPAIUA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sm <br /> Nems of CUPA/LIA <br /> ADDRESS <br /> CITY If certifier is other than CUPAILIA eharxt appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sda CERTIFICATION TIME ❑ Cenilled Safety Professional(CSP) <br /> ❑ Certified Mann Chemist(CMC) <br /> ❑ Registered EmAronmenul Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class It Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance carldIcate) <br /> ❑Yes ❑No This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere Shap be rechecked with a combustible gas <br /> indicator prior b work being conducted an the tank. <br /> Carbfises lank management instructions far scrap dealer,disposal facility,etc: I <br /> I <br /> A copy of MIX camficate shall accompany pre tank to the recyciingldispusal facility. <br />