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TANK CLOSURE CERTIFICATION FORM <br /> nr- <br /> ai.aieEaa Raa i2Uc� LtzSi h 1=1i bk Gt3 <br /> s - <br /> vre+oaaess ro. <br /> R50 EaAA- M"cxz. AuehuE <br /> &la�nEig CITU �� 1as ausiMEsg nF�j r� 06 <br /> T,IHM CNNER � �('' 1 <br /> -1'l."IskUy 1w t.L ds l h <br /> Ta.x( ER ADDRESS ipt <br /> `7635 <br /> TARNDVMeRCIr•r yfQ gTATE !oa DV SM <br /> C� <br /> Tank a Flammaole Vaper Oxygen <br /> (State Tank IDs,if applicable) Top Center action Top CenterBottom <br /> Tank Interior �\ (y <br /> OA <br /> Atmosphere C ry t_ 060 q 6- <br /> Readings <br /> CAL 000 k2-O, 46l <br /> i <br /> On examination of the tank,I o Mfy the tank is visually free from produm sludge.scale(thin,flaky residual of tank contents),rmseate and debri. I"her certify <br /> tha(the information prowded herein is true and accurate to the best of my knowledge, <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON Its j <br /> CERTIFIER NAME(PRINT) SO, <br /> Certifier is a representative of the CUPANA: YES ❑ NO ❑ <br /> j CERTIFIER TITLE so, <br /> Name of CUPAfUA <br /> I ADDRESS <br /> CITY If certifier is bdher Nan CUPAA JA check appropriate box below: <br /> PHONE ❑ Cendfied Industrial Hygienist(CIH) <br /> DATE CERTIFIED sok CERTIFICATION TIME ❑ Certified Safety Profesaibnal(CSP) <br /> j ❑ Certified Marine Chemot(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional En~PE) <br /> ❑ Class Il Registered Ei virdnmental Assesscr <br /> • ❑ CSLB pmnsed wrroretxor(with hazanlous aubatanca centitlpte) <br /> ❑Yes ❑No This tank previousty hell flammable or mmbustible matenals. It yes.the tank inlebor ailmosphere shall be re-checked with a combustible gas <br /> indiralor Prior to work being conducted on the tank. <br /> Canifiefs tank management instructions for asap dealer,disposal(atifrty,etc <br /> AWg ly of this certificate shalt acrnmpany the tank to the reryCirWdispbsal fackty. <br /> i <br />