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TANK CLOSURE CERTIFICATION FORM <br /> =ACH ITY I 1 <br /> IUSINESS NAME 1 FAcju Ty IO s <br /> �lCbr� 7� La'n t� <br /> ;ITE AOORESS <br /> A667Cn Rd <br /> tUSINESS CIT`/ /"`, ", ,�� �/^ n 'OS i 3USINE55.^•P 'DE <br /> ANK OWNER NAME 5oo <br /> Same <br /> "ANK OWNER AOORESS 3a1 <br /> -ANK OWNER C:Ty 502 STA-.E 503 I JP 504 <br /> it r QSLJRE INEQRMAZON <br /> Tank 2 Flammable Vapor Oxygen <br /> (State Tank ICrt, if applicable) Too Center Bottom Top Canter Bottom <br /> ank Interior <br /> >trnospnere <br /> Readings <br /> HI I <br /> (7t <br /> :)n axammatlon of the tank. I Certify the tanK Is visually free from product,sludge. Scale Ohm. laky residual of tanK contents), nnseate and oedns_ I further Certify <br /> hat the information provided herein is true and accurate to the oesi of my knowledge. <br /> :ERTIFIER SIGNATURE I STATUS CR AFFILIATICN OF CERTIF ONG PERSCN 50 <br /> 5 <br /> �:ERTIFIER NAME(PRINT) spa Certifier Is a representative of the CUPAIUA: YES ❑ NO ❑ <br /> 'ErRTIFIER TITLE 507 <br /> Name of CUPA/UA <br /> ADDRESS <br /> If certifier's other than CUPA/UA check aOPropnate twx gebw: <br /> :try <br /> 'HONE I ❑ Certified Industrial Hygienist(C;H) <br /> Certified Safety Professional(CSP) <br /> SATE CERTIFIED sae CERTIFICATION TIME ❑ <br /> ❑ Cer ifled Marine Chemist(C.MC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE? <br /> ❑ Class II Registered Ernmonmennl Assessor <br /> ❑ CSLB licensed contractor(wrrth hazardous substar cs certrAnte) <br /> ❑ Yes ❑ No fits tank prevrousry held lammabte or combustible materials. 'f yes. the tank interior atmosphere shad be re-Utecxed*nth a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiers tank management instructions`or scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyCing/disoosal facility. <br />