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TANK CLOSURE CERTIFICATION FORM <br /> �c� x <br /> I EACH TV 10FN11I <br /> aUSiNESS NAME 1 PACtU iY las t <br /> I <br /> 317E•CCRESS <br /> fOt i <br /> BUSINESS CITY i05 dU51NE55IIP tpd <br /> TANK CnNEA NAME 5W <br /> I <br /> TANK ChNEA A00ASS5 301 <br /> 1 <br /> TANK C.NNER CITY <br /> 742 STATE SW I IIP k,.. <br /> A I <br /> Tanks 'clam le Vapor Oxygen <br /> (State Tank ICS,if p ble) <br /> TopI Aenter Bottom Top Center i3odom <br /> Tank Interior <br /> Atmosphere <br /> i <br /> Reac:ngs <br /> I � I <br /> i <br /> Cn examination of the tank.I cenity the WK is usually from product.sludge.scale( in,flaky residual of tank contents),nnseate and aeons. I further Centfy <br /> j :hat the information provided herein is true and aCCil a to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING P!ERSCN :cs <br /> CERTIFIER NAME(PRINT) sod Certifier is a representative of the CUPAAJA: YES ❑ NO Q <br /> CERTIFIER TITLE sm <br /> Name of CUPA/L1A i <br /> ADCRESS <br /> CIT'! <br /> If certifier is other than CUPA/UA check appropnate box beknv: <br /> I PHONE ❑ Certified Industrial Hygienist(CIH) <br /> LATE CERTIFIED sos i CERTiFiCATION TIME ❑ Certified Safety Professional(CSP) <br /> C Cartifled Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RFHS) j <br /> Q Professional Engineer(PE) <br /> i <br /> ( Q Class If Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> I ❑Yes C N This tank previousty held flammable or combustible matenaw. If yes,the tank interior atmosphere shall be re-Checked with a comcusuble gas <br /> f indicator prior to work being conducted on the tank. <br /> Cardflers tan management insbttcttans for scrap dealer,disposal facility,etc: <br /> i <br /> i <br /> f <br /> JI <br /> I <br /> i A copy of this certificate shall accomoany the tank to the recycting/disoosat facility. <br />