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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME 3 FACRJTY 10• 1 <br /> SITE AOORESS <br /> 1a <br /> ,4 <br /> BUSINESS cltt 1, _ nil /� 105 au Es� lL _ 106 <br /> TANK OWNER NAM ( 5pe <br /> 7 ( C. <br /> rANK OvINER ADDRESS Sol <br /> 1 1 _ <br /> TANK OWNER CITY 502STA5W EIP SW <br /> yr ,tG ATE a;_ <br /> 11 TANK 'I QS1 ME INECEMAZION <br /> Tank# Flammable Vapor Oxygen <br /> (State Tank IDD.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> On examination of the tank.I certiy,the tank is visually free from product,sludge.scale(thin,flaky residual of tank contents)•rinseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON WE <br /> CERTIFIER NAME(PRINT) 50e Certifier is a represemative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE $m <br /> Name of CUPA/LIA <br /> ADDRESS <br /> CITY If certifier is other bran CUPAILIA check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemed(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> ❑ CSLB licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the lank. <br /> Certifiers tank management instructions for soap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyc ing/dissposal facility. <br />