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TANK CLOSURE CERTIFICATION FORM <br />Tank # Flammable Vapor Oxygen <br />(State Tank ID#, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior G, — //, j % �L <br />Atmosphere / (�J — / I J ¢ I I <br />Readings <br />111 CERTIFIrATION <br />BUSINESS NAME <br />3- FACIIJTY 10 s 1 <br />SITE ADDRESS <br />104 <br />OR AFFILIATION OF CERTIFYING PERSON 505 <br />BUSINESS CITY / <br />105 <br />BUSINESS ZIP 105 <br />TANK OWNER NAME S / <br />C /^ <br />SOD <br />/ <br />TANK OWNER ADDRESS <br />501 <br />TANK OWNER CITY <br />502 <br />ST/�,TE SOJ II j, _ 50+ <br />Tank # Flammable Vapor Oxygen <br />(State Tank ID#, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior G, — //, j % �L <br />Atmosphere / (�J — / I J ¢ I I <br />Readings <br />111 CERTIFIrATION <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 debris. I further certify <br />that the information provided herein is tru an accurate o the best of my knowledge. <br />CERTIFIER SIGNATURESTATUS <br />OR AFFILIATION OF CERTIFYING PERSON 505 <br />CERTIFIER NAME (PRINT) sob s Z, ' ' <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER TITLE soT <br />Name of CUPA/1JA <br />If certifier is other than CUPA/LIA check appropriate box bekrw: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />ADDRESS*(� S <br />CITY r' B S ll <br />PHONE — < — <br />DATE CERTIFIED <br />CERTIFICATION TIME <br />/soa <br />T ` o <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RE'HS) <br />❑ Professional Engineer (PE) <br />❑ ass 11 Registered Environmental Assessor <br />LB licensed contractor (with hazardous substance certificate) <br />U' Yes ❑ No This tank previously held 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 />Cartifiers tank management instructions for scrap dealer, disposal faality, etc <br />A copy of this certificate shall accompany the tank to the recyaing/disposal facility. <br />