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TANK CLOSURE CERTIFICATION FORM <br /> � d <br /> BUSINESS NAME S FACI4T 10• + <br /> M <br /> SRE +DORESs <br /> BUSINESS OTY +05 ausmESS ec +0B <br /> TANK OMMER NAME SW <br /> TANK DwNER ADOREss �+ <br /> TANK DWNER CITY SD2 STATE SW <br /> Tank tC Flammable Vapor Oxygen <br /> (State Tank IDs.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Inlenor <br /> Atmosphere <br /> Readings <br /> III (.FRTIFIrATION <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 peons. 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 545 <br /> CERTIFIER NAME(PRINT) Will Certifier is a representative of the CUPAILIA: YES ❑ NC ❑ <br /> CERTIFIER TITLE sm <br /> Name of CUPAILIA <br /> ADDRESS If certifier is other than CUPAIUA check appropriate box below: <br /> Cm <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer TE) <br /> ❑ Class It Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certficate) 1 <br /> ❑Yes ❑ No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-cneCred with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management instructions for soap dealer.disposal faciMy,etc <br /> A copy of this cartificate shall accompany the tank to the recyciing/disposal facility. <br />