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E— TANK CLOSURE CERTIFICATION FORM <br />0 <br />TANK QWNIIA ADDRESS Sol <br />TANK MOVER CITY !a2 STATE SOS up <br />In rFRTjF1rAT1QN - _j <br />On Examination of the tank. I certity the tank is visualty free from product, sludge. scale (thin, naky residual of tank contents), rinseate and debris. I further c9nifY <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 sas j <br />CERTIFIER NAME (PRINT) sw Cartitier is a representative of the CUPAAJA. YES [3 NO ❑ <br />CERTIFIER TITLE soy Name of CUPARJA -- <br />!! <br />ADDRESS if cerdrw is other than CUPAfl.IA check appropriate box below. <br />CITY ❑ Certified Industrial Hygienist (CIH) <br />PHONE <br />DATE CERTIFIED sas CERTIFICATION TIME ❑ CerUAed Safety Professional (CSP) <br />© Canfded Marine Chemist (CMC) <br />❑ Registered Environmental Health Specisltst (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class it Registered Envirorutww Assessor <br />❑ CSLB licensed contractor (with hazardous M" arwe oeretilcxte) <br />❑ Yes ❑ No This tank prewou* Reid flammable or combustible materials. If yes. the W* ktterior atrndsphere shalt be n-dteCked watt a co ustrtrie 4as <br />indicator prior tm work being cartdu&Ad on the tank. <br />Cart941aYs tank management insorucdons for soap dealer. disposal facrity. etc: <br />A copy of this csrtifcats shag accompany the tank to <br />Tank Interior <br />Atmosphere <br />Readings <br />Tank t <br />(State Tank IDS. if applicable) <br />Flammable Vapor <br />Oxygen <br />Top Center <br />Bottom Top <br />Center <br />Bottom <br />In rFRTjF1rAT1QN - _j <br />On Examination of the tank. I certity the tank is visualty free from product, sludge. scale (thin, naky residual of tank contents), rinseate and debris. I further c9nifY <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 sas j <br />CERTIFIER NAME (PRINT) sw Cartitier is a representative of the CUPAAJA. YES [3 NO ❑ <br />CERTIFIER TITLE soy Name of CUPARJA -- <br />!! <br />ADDRESS if cerdrw is other than CUPAfl.IA check appropriate box below. <br />CITY ❑ Certified Industrial Hygienist (CIH) <br />PHONE <br />DATE CERTIFIED sas CERTIFICATION TIME ❑ CerUAed Safety Professional (CSP) <br />© Canfded Marine Chemist (CMC) <br />❑ Registered Environmental Health Specisltst (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class it Registered Envirorutww Assessor <br />❑ CSLB licensed contractor (with hazardous M" arwe oeretilcxte) <br />❑ Yes ❑ No This tank prewou* Reid flammable or combustible materials. If yes. the W* ktterior atrndsphere shalt be n-dteCked watt a co ustrtrie 4as <br />indicator prior tm work being cartdu&Ad on the tank. <br />Cart941aYs tank management insorucdons for soap dealer. disposal facrity. etc: <br />A copy of this csrtifcats shag accompany the tank to <br />