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TANK CLOSURE CERTIFICATION FORM <br />sm abpREyss/ <br />i / `s �Pi/ 105 aU51NE55 LP 'C6 <br />BUSINESS CITY— �S <br />r >� <br />TANK OWNER NAME J <br />I <br />L O i i01 <br />TANRl SRAOOREW <br />L <br />t.00 <br />STATE 503DP `Aa7Atrnasphere <br />INFORMAJIQL <br />Flammaole Vapor Oxygen Top Center Bottom Top Center Bottom <br />I <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 Candy <br />that the information provided herein is true and accurate to the best of my knowledge' STATUS OR AFFILIATION OF CERTIFYING PERSON scs <br />CERTIFIER SIGNATURE <br />Certifier is a representative of the CUPA/LIA: YES LJ NO <br />CERTIFIER NAME (PRINT) soe <br />CERTIFIER TITLE sat Name of CUPA/LIA <br />ADDRESS If certifler is other than CUPA/LIA check appropriate box below: <br />CITY ❑ Certified Industrial Hygienist (CIH) <br />PHONE ❑ Certified Safety Professicnal (CSP) <br />DATE CERTIFIED sm CERTIFICATION TIME <br />❑ Certified Marne Chemist (CNC) <br />❑ Registered Environmental Health Specialist (RFiiS) <br />Q Professional Engineer (PE) <br />Q Class II Registered Environmental Assessor <br />❑ CSLS licensed contractor (with hazardous substance certificate) <br />Cl Yes ❑ No This tank previousty held flammable or cembustible materials. 11 yes. the tank interior atmosphere Shall be re -checked wifh a combustible gas <br />indicator prior to work being conducted an the tank. <br />.._..�_.. ....v mamaemant instructions for scrap dealer, disposal facility, etc: <br />this artifiwte shall accompany the tank to the <br />