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�' P1ANfC CLOSURE CERTIFICATION FORM <br />�� w��)RM,1� <br />iaCT <br />lives <br />STATUS OR AFFILIATION OF CERTIFYING PERSON m <br />Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br />Name Of CUPA/LN <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />[3 Certified Sarin Professional (CSP) <br />CERTIFIER NAME (PRINT) sols <br />9u51NEaa carr <br />AOORESS <br />CITY <br />+os <br />auswEssnde <br />`u) <br />OWNER NAME <br />SOU <br />iTANK <br />U <br />1 <br />FC <br />L <br />-- t% UC I <br />TANK OWNER ADDRESS <br />❑ Professional Engineer (PE) <br />01 <br />Nle, T(zm <br />WAY Suim <br /># 110 <br />❑ CSLB licensed mmractor (with hazardous substance certificate) <br />TANKONNERCITY <br />Yes No <br />indicator prior to work being conducted on the tank. <br />502 <br />STATE S0a <br />MP SW <br />i <br />It TANK-' -1 051 RE INFORMATION <br />Tank 6 Flammable Vapor Oxygen <br />(Slate Tank 106, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings n <br />L <br />On examination of the tank. I cenity, the tank is visually tree from product. sludge. scale (min. 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 <br />STATUS OR AFFILIATION OF CERTIFYING PERSON m <br />Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br />Name Of CUPA/LN <br />If certifier is other than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />[3 Certified Sarin Professional (CSP) <br />CERTIFIER NAME (PRINT) sols <br />CERTIFIER TITLE SOT <br />AOORESS <br />CITY <br />PHONE <br />GATE CERTIFIED side <br />CERTIFICATION TIME <br />C1 Certified Marne Chemet (CMC) <br />❑ Registered Environmental Health Specatist (RE+S) <br />❑ Professional Engineer (PE) <br />❑ Class II Registered Environmental Assessor <br />• <br />❑ CSLB licensed mmractor (with hazardous substance certificate) <br />This tank previously held flammable or combustible materials. If yes. the tank interior atmosphere shall be re -checked with a combustible gas <br />❑ ❑ <br />Yes No <br />indicator prior to work being conducted on the tank. <br />Canifiefs tank management instructions for scrap dealer. disposal faCility. etc <br />certificate shall accompany the tank to the <br />