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TANK CLOSURE CERTIFICATION FORM <br />r .11 jnFNTIFICATI0N <br />that the information provided herein is true and accurate to the best of my knowledge. <br />SUSINEss NAME <br />0 <br />FACIUl ID • + <br />sriE ADDRESS <br />CERTIFIER TITLE Sot <br />auslNEas QTY <br />ADDRESS <br />105 <br />auslNEss LP 105 <br />TANK ER "ME <br />T ,', r <br />1. 1 6 <br />nn ^, .. <br />y\✓�✓'t.L.J V <br />$ N <br />TANK OWNER ADDRESS <br />3t& <br />CL�J oN �it-0t7g 220 <br />TANK OWNER CI <br />SA4-J <br />❑ Registered "Environmental Health Specialist (REriS) <br />Soo <br />SATE 505 <br />I MP 50, <br />9 <br />❑ Crass II Registered Environmental Assessor <br />• <br />❑ OSLB licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes, the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted on the lank. <br />Cardfiefs tank management instructions for scrap dealer, disposal facility, etc: <br />Tank i <br />(State Tank ID*, if applicable) <br />Rammable'Japor <br />Oxygen <br />Top Center Bottom <br />Top <br />Center <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <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 certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON 'os <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) sm <br />CERTIFIER TITLE Sot <br />Name of CUPA/LIA <br />It certifier is other than CL1PA/LIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Pmfessionaf (CSP) <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sae <br />CERTIFICATION TIME <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered "Environmental Health Specialist (REriS) <br />❑ Professional Engineer (PE) <br />❑ Crass II Registered Environmental Assessor <br />• <br />❑ OSLB licensed contractor (with hazardous substance certificate) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />If yes, the tank interior atmosphere shall be re -checked with a combustible gas <br />indicator prior to work being conducted on the lank. <br />Cardfiefs tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyding/disoosal facility. <br />