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s <br /> E:::::::TA:NKCLOSURE CERTIFICATION FORM <br /> rnAl <br /> 3--------------- <br /> Aj <br /> FAGUIY p <br /> B1151NE55,wME a� <br /> M <br /> 9RE a0pAE55 y-� ��,/_ <br /> l/ <br /> ✓V l�aUWE55 aP 5os <br /> BUSINESS CRY �p <br /> 1' TANK OWN131 NAME ©� - <br /> iol <br /> TNI,alN ADDRESS <br /> 502 STATE 503 I DF <br /> TANKON CITY <br /> Oxygen <br /> Tank S Flammable Vapor Comer Bottom <br /> (State Tanx ICS.if appxnt <br /> mble) Top Ceer Bottom Top I <br /> Tank Interior <br /> Atmosphere I <br /> Readings <br /> TICINI <br /> rinseate and debris- I further certify <br /> On examination of the tank.I certify the tank is visually free from product sludge,scale(thin.flaky residual of tank convents), <br /> that the information provided herein is true and accurate to the best of my knowledge. STATUS OR AFFILIATION OF CERTIFYING PARSON <br /> I <br /> CERTIFIER SIGNATURE Certifier is a representative of the CUPAUk YES Q NO 13 <br /> CERTIFIER NAME(PRINT) Soo <br /> CERTIFIER TITLE stir Name of CUPAILIA <br /> ADDRESS <br /> If certifier is other than CUPAILIA chant appropriate box below: <br /> CITY Q Certified Industrial Hygienist(CIH) <br /> PHONE ❑ Certified Safety Pratessional(CSP) <br /> DATE CERTIFIED M CERTIFICATION TIME <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> Q Professional Engineer(PM <br /> Q Crass II Registered Environmental Assessor <br /> ' ❑ CSLB licensed convector(with hazardous substance <br /> certificate) 1 <br /> This tank previously hey fiantmable or cembustihle materials. 11 yes.tiro tank interior atmosphere Shall he re-dtetltad with a combustible gas <br /> ❑Yes ❑No indlntpr prior to work being conducted on Me tank. <br /> Certifiees tank management inSiNctiprrs for SaaP dealer,disposal facility,etc <br /> I <br /> A copy o{this certificete shalt accompany the tank y the reCyCing/di5posal facility. <br />