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YANK CLOSURE CSRrimcATiON FORM <br />"I"s a <br />i 1=arn i'" Incr.rr me a nnwr <br />BUSINESS NAMO a <br />rAcluTY Ina 1 <br />Top Center Souom Top <br />Center <br />SITS AWR= <br />,aa <br />c) <br />BUSIN&SS CITY B 105 <br />® <br />3U 109 <br />TANK CVWJ R NAME sm <br />GJ Lrcg Pir., 4 <br />TANK CVMER AooRew <br />i <br />TANK OWNER CITY 1az <br />$'rA*M 501 <br />IIra 504 <br />�IAX-rWf:Z. <br />Tank 3 <br />(Slats Tank LOS. if applicable) <br />Tank Interior <br />Atmosphere <br />Readngs <br />Flammable Vapor Oxygen <br />Top Center Souom Top <br />Center <br />sattotn <br />f <br />1 <br />On examination of the tank. t certify the tank is visually free fi�om product. sludge. scale (thin. flaky residual of tank cantema , rinseate and aeons_ I huller cenify <br />that the information provided herein is we and accurate to the best of my knowledge__ <br />CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PSASCN soy <br />CERTIFIER NAME (PRINT) soo <br />Certifier is a representative of the CUPAn1A: YES Q NO Q <br />CERTIFIER TITLE sot <br />Name of CUPAlLIA <br />At�ORESS G If ceniser is other than CUPARIq chemo <br />CITY appropriate box Wow <br />PHONE Aw) 6141-,6390 <br />❑ Cerdfiad Industrial Hygienist (C%H) <br />DATE CERTIFIED so9 CERTIFICATION TIME ® Certified Safety PmN=i=W (CSP) <br />® Certified Marine Chemist (C.%10) <br />Q Registered Environmental Health Specialist (RENS) <br />Q Professional Engineer (PE) <br />Q Class It Registered Environmental Assessor <br />Q CSLBI licensed contactor (with hazardous substance certificate) <br />❑ Yes ® No This tank previously held ftarnmable or combuso'bie materials, it yes, the tank interior atmosphere shalt be re•ctiecked with a cambustible gas <br />indicator prior la work being conducted an the tank. <br />Cartifiets tank management Irmtructlons for strap dealer. disposal f mKy, etc <br />A copy of this certificate shalt accompany the tank to the recyding/disposal facWty. <br />6Z 39Vd 80014 H1dYd 6EVE89060Z t0:60 000Z/Li/S0 <br />