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TANK CLOSURE CERTIFICATION FORM <br /> 'qA or <br /> BUSINESS NAME 3 .AGUIY Ian 1 <br /> aITE +ooRESs :0A <br /> a SINESS av i05 34.JS11"Ess ZIP 105 <br /> TANK G ER NAME 50e <br /> 'ANKO RADORES$ 301 <br /> TAMK OWNER CRY Sat I TATE Sea I ZIP 3oA <br /> Tank is Flammable Vapor Oxygen <br /> (State Tank IC*.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III (7.'I=RTIFICATIQN <br /> On examination of the tank. 1 certify the tank is visually Bee from product sludge.scale(thin•laky residual of tank mntems),nnseate and deans. I further certify <br /> that the information provided herein is true and aCctirate to the oest of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON Sas <br /> CERTIFIER NAME(PRINT) 506 Certifier is a representative of the CUPAA.:A: YES ❑ NO Q <br /> CERTIFIER TITLE wi <br /> Name of CUPA/UA <br /> ADDRESS <br /> CITY It certifier is ether than CUPA/LIA checkappropriate box below <br /> PHONE ❑ Carolled Irldttsthal Hygienist(C:H) <br /> DATE CERTIFIED sow, CERTIFICATION TIME ❑ CarMred Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RFriS) <br /> ❑ Professional Engineer IPE) <br /> Q Cass II Registered Emlrormental Assessor <br /> ❑ CSLO licensed contractor(with hazardous substance cerdfipte) <br /> ❑ Yes ❑ No his tank previously held flammable or combusable materials. If yes,the Mnk interior atmosphere shall oe rerltecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiefs tank management instructions for soap dealer.disposal facility,etc <br /> A may of this mmfiGate shall accompany me tank to the recyCingfdisposal fatlidy. <br />