Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br /> � _ a <br /> MSINESS NAME ] FACRJTY IDtl I <br /> C 17-Y e, r 7- A6Y 01CV- E <br /> SRe ADDRESS <br /> Io6 <br /> BUSINESS CITY CV <br /> aUSINESS LP im <br /> TANK OMNER NAME gQa <br /> C iYy 6F T�CY <br /> TANK OWNER ADDRESS gal <br /> Tra a gls' <br /> TANK DINNER CITYge3 STATE Se] DP MM <br /> Gy C4 I 95376' <br /> Tank# Flammable Vapor Oxygen <br /> (State Tank 104,it applicable) Tap Canter Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere ,�• - - - — 3 r 3 <br /> Readings <br /> III CIFIRTIETrATION <br /> On examination of the tank. I certify the tank is visually free from product sludge,scale(min,flaky residual of tank contents),rinaeate and doom. I turdw certHy <br /> that the information provided herein is true and accurate to the bes of my IVowl ge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON US <br /> CERTIFIER NAME(PRINT) ' rF J0l+tv.v Certifier is a representative of the CUPAILIA: YES ❑ NOX <br /> CERTIFIER TITLE sm �7 <br /> Name of CUPA/LIA <br /> ADDRESS 70-7j'r; /HCl <br /> CITY W C If certifier is other than CUPAJUA check appropriate box below: <br /> PHONE - _ ._ G, 7 r ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED sea CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMG) <br /> 1�// / r ❑ Registered Environmental Health Specialist(RENS) <br /> 7r <br /> ❑ Profesaienal Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> CSLS licensed contractor(with hazardous substance certificate) <br /> Yes ❑No This tank previously held flammable or combustible materials. if yes.tie tank interior atmosphere shelf be ns-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifler•s tank management instructions for scrap dealer,disposal facility,at= pb J04,7, <br /> uT i 4&k WX:rHPtlT ros rr,�d6 <br /> FSR �ifSOU.aL COA14 +s rr.3<E rgpOr7.tc,�tf <br /> � a b <br /> A copy of this certificate shall accompany the tank to rine rerydingidisposal facility. <br />