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TANK CLOSURE CERTIFSCATION FORM <br />111 CERTIFICATION <br />BUSINESS 3 1 <br />5ACI4tV ios i <br />SITE ADDRESS 104 <br />aUSINESa CITY 105 <br />ausinj4va 766 <br />TANK OWNER NAME 500 <br />TANK CWN.ER ADORES$ 501 <br />7Z,e!!P/l <br />TANK OWNER C1T`!S02 <br />STATE� <br />I ZIP� � 504 <br />ADDRESS <br />_ <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />Tank # <br />(State Tank ID0. if applicable) <br />Flammable Vapor Oxygen <br />Tank Interior <br />Atmosphere <br />Readings <br />Top Center Bottom Top <br />Center <br />Bottom <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PEI <br />❑ Class Ii Registered Environmental Assessor <br />❑ CSLB Licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes. the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted an the tank. <br />Czrtifier's tank management instructions for scrap dealer, disposal fadlity, etc: <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />111 CERTIFICATION <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 debris. I further certify <br />that the information provided herein is true and accurate to the best of my knowiedge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br />Certifier is a representative of the CUPAILIA: YES 0 NO ❑ <br />CERTIFIER NAME (PRINT) soe <br />CERTIFIER TITLE soy <br />Name of CUPA/LIA <br />If certifier i5 other than CUPAILIA ctredc appropriate box below: <br />ElCertified Industrial Hygienist (CIH) <br />Certified Safety Professional (CSP) <br />ADDRESS <br />_ <br />CITY <br />PHONE <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PEI <br />❑ Class Ii Registered Environmental Assessor <br />❑ CSLB Licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes. the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted an the tank. <br />Czrtifier's tank management instructions for scrap dealer, disposal fadlity, etc: <br />A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />