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TANK CLOSURL IAF H I if'CAT IUN FORM <br /> vvs,nEs•..•u IDSfLY(� //'y�T I��G11.1T 0ENTiFIGATIQN iW5, <br /> - <br /> • � � sAGun wSOO <br /> v*eBUMLESS / tasTA..port STATE 1103 DP 1W <br /> Tank a Flammable Vapor omen <br /> (State Tank IDs.s applicable) Tap Center Bottom Top Center Bottom <br /> Tank Interior <br /> Reoingsere <br /> Readings 70/ <br /> 9-oa3 <br /> III rFPTIR( ATIQM <br /> On examination of the tank.1 cenify,the tank is visually free from product.sludge.scale(thin.daft,residual of tank mnteniz),tinseate and debris. 1 further certify <br /> that the information provided herein is We ane accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sas <br /> CERTIFIER NMIE(PRINT) sad CZTi Is a representative of the CUPAr-W YES ❑ NO ❑ <br /> CERTIFIER TITLE !w <br /> L t Name of CUPP/UA <br /> ADDRESS � <br /> CITY If certifier is other than CUPAIUA check appropriate box below: <br /> PHONE a ❑ Certified Industrial Hygienist(CIH) <br /> DATE CE(ZTIFIED sm CERTIFI O C3Cerdded Safety Professlwml(CSP) <br /> �)L. /V- X Certified Marina Chemist(CMC) <br /> � ❑ <br /> Registered Emiranmenul Health Spedalisl(Re?i5) <br /> Lvr ❑ Professional Engiraer(PQ <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance cenifiala) <br /> ❑No This tank previousty,hod dammable ormmbustlb1c materials. It yes.the tank interior abnosphere stag be no-cirmc ked with a comousti gas <br /> indicator prior to work being conducted on dor tank. <br /> Camnars tan,man:gemem Insruoloru far scrap dower.disposal taaley,etc: <br /> _Cony dl till:f.Ynlfi:.ife shag accnmpany d:C link to d'C Mcyc'inotdisnas]t batty, <br /> 1 <br />