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r-1 <br />TANK CLOSURE CERTIFICATION FORM <br />0 <br />' F 3 <br />PAC:USV �0 • , <br />BUSINESS NAME <br />� <br />,o. <br />sme ADDRESS <br />'O5 3US E55.:'P 'ADD <br />9tlswess CITY <br />;m <br />TANK OVYIIER NMAE <br />�t <br />TANK ON !R AOORESS <br />Sat a ATE 503 JP <br />TANK dvmEl GN <br />I <br />Tank e <br />(State Tank IC;%. if applicable) <br />Tank Interior <br />Atmosphere <br />Readings <br />Bottom <br />On examination of the tank. I certify the tank is visually free from pros sludge. scale (thin. flaky residual of tank comems), rktseate and aeons. I f Mer certify <br />that the information provided herein is title and accurate to the best of my knowledge <br />r• 7 RC(`N 5115 <br />:ERTIFER NAME (PRINT) 501%Cartifier is a representative of the CUPAA.IA: YES 1.1 Nl� tl <br />9i -'n IFR TITLE sm Name of CUPAA.IN <br />,DDRESS If certifiers other than CUPAIUA check appropriate dox below: <br />;ITY Q Camfied Industrial Hygienist (Cal) <br />rHONE Q Certified Safety Professional (CSP) <br />)ATE CERTIFIED 51111 CERTIFICATION TIME <br />❑ Certfietl Marine Chemist (CMC) <br />Q Registered Environmental Health Soecalist (RENS) <br />Q Professional Engineer (PE) <br />❑ Class It Registered Environmental assessor <br />❑ CSLO licensed cpmraaor (with hazardous substance certificate) <br />re-dtecke6 with a com0us1i01e gas <br />Q Yes C]No This tank previously held flammable or odmousable materials. It yes. the WK imenor atmosphere stud Oe <br />indicator prior to work being conducted on the tank. <br />Cartifiefs tank management insppcdons for swap dealer. disposal faclity, etc <br />A Copy of this certificate Shall accompany the tank :o <br />