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10/17/2000 09:00 20946V 93 FIFTH FLOOR PAGE 12 <br /> TANK CLOSURE CERTIF)t:A,TION FORM <br /> TIM- 7Im CoO�r- w%L,. cav+P�R'1 "'. ? k1S ai S i. ►aa. <br /> aua'A�asa aAMp <br /> ! t•AQYT'q• 1 <br /> PACIFIC AVENUE ARCO STATION <br /> erre ADQ%255 <br /> tW <br /> 6425 PACIFIC AVENUE <br /> a�*lhlt aair. rZTOCKION , CA •os 04USLNLW ZIP ,oe <br /> T. k9M9P <br /> MASON EN ARK YEKTA1 <br /> jai <br /> P. O. BOX 2228 <br /> ` spt <br /> TAMk t ANVILLEr '. STAT O- <br /> CA 50 fj <br /> Tanks Fwrrhmable Vacer Okygen <br /> tstata Tank toll.it appkalft) TaP Canter 80t]asn Top Center 809om <br /> Tank intudor <br /> Atmaapheta <br /> Reagings <br /> 111 CFRTIFICATION <br /> On eramewtion of the tank.l certify the tank A lieuNly free from Preduel sluege.scale(titin.Racy opal of tank comeMs).do em and dood& 1 Lvilhor wrtY.y <br /> Vial me htlblMaaen providad herein i0 Inn and go&"ra to M best of my.sng jedge. <br /> CERTIFIER 11cwATURE STATUE Qlt AFFiLtA.T1ON OF CSBTFYINO Pl"ON scs <br /> CUT—IFIER Nneie(PRIVY) am CartMw is a mpresennove of me CUPA41IA YES Q NO ❑ <br /> CERTIFIER TfTI! ao7 <br /> Name of CUPAMIA <br /> A00RES9 <br /> CITY tf oertiffor a other than CUPAILIA rllotlt appmpnate bo=bdim: <br /> PHONE ❑ CeNlled wultbl Hygienist(C3K) <br /> OAT@ CERTIFIED Soo ClAnFICATION TIME Q cam" PMapland(CSP) <br /> Q Car117ed Moine Cnemiet(CMM <br /> ❑ Registered Es vifpnmw"Heeaft SW*&ltst(REr(S) <br /> Cr Profeaalonal tnginaer(PE) <br /> Q C:as!If f 9istated Enwa.rtennl Asseasar <br /> Q 031-8 licensed ooraaator(Mint mxemow substsnc e r rtytScate) I <br /> Q Yes Cl No incift��«m www % U�'�oNaa isule matenais. a yes.«u Tank YKeAor awmwers wv a be m-dsadm xdn a w +noble-4" <br /> Cwufw'x tank awmKomant--Uugwwm fel sgrep daela;.d6ap"Al ,A= <br /> A Copy of of eetttacate snea accompanY trta tank•to rhe recycHewc llowal fad&ty, <br />