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TANK CLOSURE CERTIFICATION FORM <br /> h9+ a <br /> - — <br /> eVSuKESS MAJAE, 1 FAQUV 10• <br /> �t - - -- 10+ <br /> SR A00RESS <br /> BUSINESSCITY ICs 3USWESS ZJP toe <br /> S <br /> faNK C%*MU NAJAF SW <br /> , P _ <br /> TA, ER ADDRESS <br /> -Awn OWNER C Tv Soz STATE 581 ZIP <br /> 4 ' Tanks Flammabte Vapor Oxygen <br /> I (State Tank 1Os If applicable) Top Center Bottom Top Canter Bottom <br /> t <br /> I TanK Intenor ! <br /> Atmcspnere 11 <br /> �j Reaoings <br /> i <br /> i <br /> tit CERTIFICATION <br /> 1 <br /> i <br /> I <br /> On examinatton of the tank I certify the tank is visually free from product sludge scale(thin laky residual of tank contents) nnseate and aeon- t Ayther cert <br /> t that he information provided herein is true and accurate to the best of my knowledge <br /> t <br /> CERTIFIER SIGNATURE STATUS OR AFFIL IATIQN OF CERTIFYING PERSON os <br /> i CERTIFIER NAME(PRINT) 5011 Cardfler is a representadve of the CUPNLW YES ❑ NQ Cl <br /> CERTIF ER TITLE $07 ' <br /> Name of CUPAA-A <br /> AOORES5 If cernffer is other than CUPAILIA check appropriate Goz below <br /> CITY ❑ ' <br /> � Certilfad tndttstnal Hygien-t(CIH) <br /> PHONE <br /> t ❑ Certified Safety Professwnat(CSP) <br /> DATE CERTIFIED umJC)ERTIFICATION TIME , <br /> ❑ Gertrtted Manna chemist(G�+1C) <br /> ❑ Registered Ertwonmental Health 5peaatkst(Ft>=h5)❑ Prafesstanal Engineer(P_E) <br /> _,/Class ii Registered Ermronmental Assessor <br /> -6d_ CSLB gcerued commctw(with hazardotu sutntance arbtcatel <br /> s ❑ This tank previously held flammableCombustible <br /> or materials If yes the tank Intenor atmosphere shall be re-chocked virstli a combusnbl <br /> Yes No as <br /> - - indlcator pnor to work being ronducted on the tank <br /> t C.arifiers an management u-trueJons for scrap dealer dispoaat facility e1r ' <br /> i tf � II <br /> i� <br /> , <br /> 1 <br /> r <br /> j I I <br /> A copy of this certificate shalt acrampany the tank to the recydutig/dispasat faaltry <br /> s <br />