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I C } � 2 <br />' TANK CLOSURE CERTIFICATION FORM <br /> Tq� d <br /> I EACH Cry IQEW-nEJ(-A33Qm- <br /> 10• t <br /> AN R <br /> jr aOorcEss <br /> +a <br /> w AZ 5� —o mZ S <br /> SF"fiSS GTY C> A` 106 2U�zip 100 <br /> OWNER NAME sm <br /> K Qvwim AMREU <br /> NM V-- t <br /> ANK OVYNEA CSTY AA sm STATE Sal I aP sm <br /> C�L v e <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank 100 if appitcawei Top Center Bottom Top Center Bottom <br />'ank Interior I <br /> rsprwo <br /> adengs <br /> I� <br /> axar matron of the tank 1 certify the tank m wsatraily five from product,sludge scate(thin flaky rescdual of tar&cmental.rmseate and desrss. t fuller candy <br /> WWII Infofmadon provided herein is true and accurate to the best of my knowledge <br /> RT[FI ER SIGNATURE STATUS OR AFFILLA110M OF CERTIFYING PERSON sos <br /> TIFIER MAME(PRENT} —so Cartslll er is a mpraserrtattre of the CUPMtA YES ❑ NO ❑ <br /> ERTIFiER TfRE sot <br /> Name of CUPAA.JA <br /> DRESS <br /> WY If anfier is other than CUPAfLIA dtedc appropriate box below <br /> HONE ❑ Certified Industrial Hygmust(CIH) <br /> r CERTIFIEDD sour CERTIFICAMN TIME ❑ Certified Safety Pmbsaronal(C$P) <br /> © Certified Marine Cheri(C.1mq <br /> ❑ Regsstefed Ersys*mw tat HeSM Speaakst(RENS) <br /> ❑ ProfesSwnat (PE) <br /> ❑ Class II RegrStered F emu mental Ammaar <br /> ❑ CSLB licensed Contractor(with hammlous adman Ovrtifipte) <br /> Yes Cl No This tank Pr§vwuslY held flammable or combustible matenakL If yes the tank arterior aartosphere shall be re-dsedted wills a combustible gas <br /> usdlc ator Prior to wrork bamg conducted an the tank. <br /> Imflers tank management insvnscoons for Scrap dealer diaposai facility.etre <br /> 0 <br /> A copy of this certificate shall accompany the tank to the recye ingidisposal fachty, <br />