Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />Tsq• � M <br />aneINE55 <br />F 1 <br />` <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA checll appropriate box below: <br />❑ Cartmel Industrial Hygienist (CIH) <br />❑ Canified Safety Professioriat (CSP) <br />ADDRESS <br />SITE ADORES <br />CITY <br />PHONE <br />DATE CERTIFIED <br />sae <br />CERTIFICATION TIME <br />,05 auSNEss LR <br />BUEINEsi CITY <br />T�—�—'T <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Enwonmental Health Soecalist (RE'riS) <br />E <br />LANK .^.'NNEn TOERE55 <br />o, <br />❑ C:ass It Registered Environmental Assessor <br />'ANN C'h,lEi CITY <br />Q CSI -13 licensed comractor (with ItaZaidOUS substance 2rtiflcate) <br />❑ Ye5 ❑ NO <br />(Slate Tank ICs. if applicable) F Top Center Bottom 'I Top I Center <br />Tank lntenor <br />Atmosphere 15 3 82- T <br />Readings <br />/S �gZO <br />/'a5— �?c9Z-,? <br />On examination of the tank, I certify the tank is visually free from product, sludge, scale (thin. flaky residual of tank contantsl, rinseato and deons. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PSRSCN sos <br />CERTIFIER NAME (PRINT) son Canifler is a representative of the CUPAJUA: YES ❑ NO ❑ <br />CERTIFIER TITLE SOT <br />Camfler's tank management instructions for scrap dealer, disposal facility, etc <br />I A copy of this cemficate shall accompany the tank to the recycingidisoosal facility. <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA checll appropriate box below: <br />❑ Cartmel Industrial Hygienist (CIH) <br />❑ Canified Safety Professioriat (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED <br />sae <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Enwonmental Health Soecalist (RE'riS) <br />❑ Professional Engineer (PE) <br />❑ C:ass It Registered Environmental Assessor <br />• <br />Q CSI -13 licensed comractor (with ItaZaidOUS substance 2rtiflcate) <br />❑ Ye5 ❑ NO <br />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 />Camfler's tank management instructions for scrap dealer, disposal facility, etc <br />I A copy of this cemficate shall accompany the tank to the recycingidisoosal facility. <br />