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TANK CLOSURE CERTIFICATION FORM <br /> 1 EACH rry IDENTOrA'i <br /> .G SS NA.0 �...t•,�t, E-/� gj Q'Y�S �`�l/1F'Zj✓^-j 6"V T a I F.cw r•t ro• <br /> >CCAESS a, — <br /> 7 <br /> 'Ess CirY fas 9usimess Dv •oil <br /> 1�� u .�/yam�^ //� �, <br /> =W"4=ji NAME /e`�+�� �1�''\ �� !/�•'� �/,I • �c'T U1�/v/,Vt <br /> o ' DE «_- <br /> :"w ea ACORESa ty` „? f� iai <br /> 1 �J V ✓i <br /> Pit- <br /> ,.%+ER Ciry �...�. � �. SaZ iTArE – I Z: SOA <br /> C-A <br /> 11 TA 1 <br /> Tank t Rammaole'Vapor Oxygen <br /> (State Tank 101.if applicable) Top Center Bottom Top Canter Bottom <br /> interior <br /> 'ingot@ / /(� / O oL I ' <br /> pings J <br /> _ i p/ %• c�. �•y p .+J�, /I Esc <br /> fit a <br /> camination of the tank. I certify the!ank is visually free from product.sludge.scale(thin.-laky residual of tank contents),rinseate and aeons. I further certify <br /> he information provided herein is true and accttate to the best of my knowledge. <br /> i IFiER SIGNATURE STATUS OR AFFILIATION OF CERnFONG PSRSCN sus <br /> TIFiER NAME(PRINT) soil Cartifler Is a rearesentattve of the CUPA/UA: YES Cl NO ❑ <br /> TIFIER TITLE so7, <br /> Name of CUPAAJA <br /> �Eao If certifier is other!tan CUPAIUA c'te&appropriate box beknv:10, i <br /> t� ❑ Cerdfled Industrial Hygienist(CIH) j <br /> ^+E G <br /> CERTIFIED son CERTIFICATION TIME ❑ Certlfled Safety Professional(CSP) <br /> ❑ Cenifled Marine Cbemrst(CUCI i <br /> /�/ �� / � ❑ Registered Environmental Health Soecalist(RE-iS) t <br /> I <br /> ej e /;;7 iL�J ❑ Profession!Eagfneer(PE) ! <br /> ❑ Cass II Registered Environmental Assessor <br /> IZ—CSLB Ikxnsed corroractor(with hazardous substance certificate) <br /> es ❑ No This tank previously held flammable or comoustible matenals. If yes.the tank interior atmosphere shall be re-dtecked with a comousuble gas <br /> Indf©tor prior to work being conducted on the tank. <br /> iers;ank management instftadon3 for saa0 dealer,disposal facility,etc <br /> A copy of this certificate shad accomparry the tank to the recyC:nglaisoosal faciity. <br />