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w s' <br /> TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME � � <br /> T FAC tUTY 10 -t <br /> SITE ADDRESS <br /> BUSINESS CITY <br /> TANK OWNER NAME rx ' X05 allSINESS LVA t� <br /> SW <br /> TANK OWNER ADDRESS <br /> TANK OWNER CITY <br /> S ^� 303 STATE 501 so, <br /> I� Com• �7�O <br /> Tank OFlammable Vapor <br /> Tank Interior Top C <br /> (State Tank too.if applicable) Top Center P Bottom Oxygen <br /> Center Bottom <br /> Atmosphere <br /> Readings 0 <br /> On examination of the tank.I cervi tank is visuallytree from product.sludge,scale(thin,flaky residual of tank contents),rinseate and debris. I further certify <br /> that the information provided her t a to the best of my knowledge. <br /> CERTIFIER NAME(P <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> T) � sos � <br /> CERTIFIER TITLE soTCertifier is a representative of the CUPA/LIA: YES C3NO ❑ <br /> ADDRS <br /> l 'N - Name of CUPA/LIA <br /> ES <br /> CITY v If certifier is other than CUPAJL(A cheek appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> /j/f / /©�� /� • <br /> CC) �ryr ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> :FR ❑No This tank previously held flammable or combustible materials. If yes,the tank Interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the lank. <br /> Carlifier's tank management insbucdons for scrap dealer,disposal facility,ate: <br /> A copy of this cartificate shall accompany the tank to Me recyding/disposal facility. <br />