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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME 3 FACILITY Q 0 1 <br /> SITE AOORESS 104 <br /> BUSINESS CITY /1��.� 105 aUSINESS IIP/��j , 106 <br /> TANK CwNER NAME i 500 % J <br /> TANK CANER ADORESS 501 <br /> TANK OWNER CITY 502 S/�i E 503 AP 504 <br /> Tank* Flammable vapor Oxygen <br /> (State Tank IC*.if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III CERTIFICATION <br /> On examination of the tank. I certify the tank is visually,free from product.sludge.scale(thin,flaky residual of tank contents),rinseate and debns. I further certify <br /> that the information provided he-min is true aqj accurate o the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSCN Sas <br /> CERTIFIER NAME(PRINT) soa Certifier is a representative of the CUPA/LIA_ YES ❑ NO ❑ <br /> CERTIFIER TITLE 5oT <br /> Name of CUPA/UA <br /> ADDRESSC, �; ` �;�j` <br /> CITY If certifier is other than CUPA/UA check appropriate box below: <br /> 2 � S <br /> ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIF115D soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Ghenust(CHIC) <br /> ❑ Registered Environmental Health Spedalist(REHS) <br /> ❑ Professional Engineer(PE) <br /> Vass II Registered Environmental Assessor <br /> ra LB licensed contractor(with hazardous substance certificate) <br /> w Yes [:1 No This tank previously heli flammable or combustible materials. If yes,the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifier's tank management instructions for scrap dealer,disposal facility,etc_ <br /> A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />