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TANK CLOSURE CERTIFICATION FORM <br /> F <br /> iREss LowF `e<; <br /> :wortE55 C ,w <br /> RAW <br /> ,m <br /> K 0VAtER w E 5110 <br /> k pVMER AOplE55 _ 501 <br /> Moo mcry <br /> Tanks Flammable vapor Oxygen <br /> (St-te Tank ICS.it applilabte) Top Cather Bottom Top Canter Bottom <br /> nk Interior #, <br /> =son" <br /> ,actings <br /> Ill rFIP71F1rAT10N <br /> a examnation of the tank.I certify the tank is Nsually free from product.sludge.stab(thin,ftaky residual of tank ramems),nrmu ate and aeons_ I further Andy <br /> at the information provided herein is true and accurate to the best of my knowbdge. <br /> ERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PARSON sm <br /> ERTIFIER NAME(PRINT) sae Certifier is a representative of the CUPAIUA YES Q NO Q <br /> ERTIRER TITLE w Cl�• r Name of CUPA/WL <br /> DDRESS _ 7 � <br /> If certifier is other than CUPA/LIA cteCk appropriate box below: <br /> tel' ❑ Certified InausitW hygienist(CIN) <br /> NONE f <br /> ATE CErFIT1FIED sm CERTIFICATION TIME Q Certified Safety (CSP) <br /> ❑ Certified Marine Owntst(CMC) <br /> ❑ Registered Environmental hlealm Specalist(RErtS) <br /> Q Professional Engmeer(PE) <br /> ❑ C7ass II Registered E,nvirorr entill Assessor <br /> CSE licensed cohtracW(With mmwdom wtistanx certificate) <br /> Yes ❑No T16 tank previously meld flammable or WrhbUSbib materials. If yes.the tank interim abnosphae stall be retirecked vAM a camourable r <br /> indicator prior to work Dein conduced on the tank. <br /> :ardfiers am managemem immn Wms for soap dearer.dsp acfily,etc <br /> A copy of this rartiftgte shall accompany the tank to the recycrng/disoosal facility, <br />