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TANK CLOSURE CERTIFICATION FORM <br /> xY9ME$axAYE i SACNiY Ibx 1 <br /> F'P-Fri S c b /U/1ScI ,TN D'ir.i— f Y— <br /> arE ,GC`U SS to. <br /> 362-14 S. Abiz-Pc>2T- W+Hi STnc4iesa.j ci4 9672o4o <br /> 9umx ;s ary ,as auswEssm .af <br /> rb N S3 m6 <br /> ; iAMx crag rave foo <br /> i MASSrE ANJGJ, <br /> I iAxx C+arq AaawE55 bf <br /> /Sri( TP4 <br /> TAnx Q/e1q GlY 502TV.-Rim Bi m I8 X. <br /> Siic cTlTaI (-A I gst3ir <br /> 11 TAN -I QSHEMINEGIRMSTION <br /> Tank s Flammable Vapor Oxygen <br /> (State Tank IW,t applicable) Tap Center Bottom Tap Cancer aaaom <br /> Tank Interior <br /> Almosphere 39-bS15631Readia C•9% <br /> III rF;RTIF?j7AT1QN <br /> On examination or the lank,1 certify the tank is visually free from prooua,sludge,sale(thin,flaky residual of tank=tens),rinseate and debris. I huther canify <br /> trial me information provided herein is we and accurate m the pest of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON :cf <br /> CERTIFIER NAME(PRINT) foe Cartier is a representative of the CUPAILIA YES ❑ NO Q <br /> CERTIFIER TITLE mr <br /> Name of CUPAILIA <br /> ACORESS <br /> CITY If rartdar is ether stun CUPAtL1A Ctetic appropriate hex below: <br /> PHONE ❑ Caroled Industrial Hygienist(CIH) <br /> OATS CERTIFI© sax CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Cerdrad Mankte Chemist(CNC) <br /> ❑ Reglsteted Ern rormee al Health Specialist(R&M) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class It Registered Environmental Assessor <br /> ❑ CSLS kensed mrnraaor(with hazardous substanm=rdfiaatel <br /> ❑Yea ❑No This tank pnwiawlY held flammaote or:amhusobfe materials. If yes.Ne tank interior afmosphem shall be M-Checked vrttt a mmbufdble gas <br /> indlmtor prior to work being rionduaed an the tank. <br /> Cararter's tank management insUaWons for saap dealer,disposal polity,enc <br /> I <br /> I <br /> A moy of this mmfi=1e shall ac=mpany the tank to the recyc!aWdisposal ladity. <br />