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%will V <br /> TANK CLOSURE CERTIFICATION FORM <br /> Paae � w <br /> aUSlryE95 tyy ] FACILITY Ib e t <br /> o 'V <br /> artE AooREss lo' <br /> / W. /teff IAM,41V JJ <br /> BUSINESS CITY 103 aUSINifn 3e3 <br /> i iAMx pyMEq ru E 300 <br /> I <br /> ' iANN PNIIER AOpRE99 >Ot <br /> TAMN MNER CItt n UoSTATE SW LP 3W <br /> Tank s Flammable vapor Orygen <br /> (Slate Tank IDR if applicable) Top Center Bottom Top Center Bottom <br /> Tank interior <br /> Atmosphere <br /> l Reading$ <br /> I <br /> III (".FIRTIFICATION <br /> On examination of the tank.I certify the tank is visually free from product sludge,scale(thin.flaky residual of tank contemn).rinseate and debris. I further certify <br /> that the information provided herein is true and acwrate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON ros <br /> CERTIFIER NAME(PRINT) Sae CaNber is a representative of the CUPAnJA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sot <br /> Name of CUPAAJA <br /> ADDRESS <br /> CITY If certifier a other dun CUPAAIA check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sore CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CNC) <br /> ❑ Registered Environmental Heats Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous SUb3tanCe certificate) <br /> 9LYes ❑No This tank previously hell flammable or combustible materials. If yes.cite tank interior atmosphere shall be re checked with a combustible gas <br /> indlator prior to work being conducted on the tank. <br /> Catcher's tank management ktstruCdbns for scrap dealer.disposal family,etc: <br /> J A ropy of this ramiliicate shad a=moany the tank to the recycting/dispbsal fadity. <br /> I <br /> 7 <br />