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TANK CLOSURE CERTIFICATION FORM <br /> P+9A x <br /> EUSINESS NAME 3 E+CIUTY I0• <br /> ' aiTE ao00.E55 iW <br /> I <br /> I <br /> i aUSINE55 CITY l05 3oSiNE55 LV raa <br /> it TANK CNMEil NAME <br /> said <br /> TANK PANER TppeES$ <br /> >Ot <br /> ANN ONMER CiTV 502 I STATc 503 I ZIP $oa <br /> Tank s Flammable Vapor Oxygen <br /> (State Tank ICs.if applicable) Top Center Bottom Top Center Bodoni <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III r.FRTIFIrATION <br /> On examination of the tank.1 certify the tank is visually free from product.sludge,scale(min,flaky residual of tank contents),nnseate and aeons. 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 sas <br /> CERTIFIER NAME(PRINT) 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sou <br /> Name of CUPA(LIA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA check appropriate box below: <br /> CIN <br /> PHONE C3Certified industrial Hygienist(CIH) <br /> DATE CERTIFIED son CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CNC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Errvironmental 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-Clerked with a combustible gas <br /> indicator prior to work being conducted on the tank_ <br /> Cartifiefs tank management instructions for soap dealer,disposal facility,etc <br /> ' A copy of this certificate shall accompany the tank to the recycling/disposal facility. <br />