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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME \ 3 FACILITY to• 1 <br /> SITE ADDRESS 104 <br /> ISPq ♦✓i <br /> allSJNESS CITY / 105 3U I S 7JP 106 <br /> 75 CA <br /> TANK OWNER NAME ./� 500 <br /> TANK OWNER ADDRESS 501 <br /> TANK OWNER C1TY 502 STATE 503 IIP 504 <br /> Tank# Flammable Vapor Oxygen <br /> (State Tank ID#,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> I <br /> III rF=RTIFIrATION <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 knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON 505 <br /> CERTIFIER NAME(PRINT) sob Certifier is a representative of the CUPA LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE 507 <br /> Name of CUPAIUA <br /> ADDRESS <br /> CITY If certifier is other than CUPAILIA check appropriate box below: <br /> PHONE 13Certified Indusinal Hygienist(CIH) <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health.Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance Certificate) <br /> ❑ Yes Q No This tank previously held flammable or Combustible matenais. If yes,the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being Conducted on the tank. <br /> Certifiers tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recydingldisposai facility, <br />