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ti. <br /> TANK CLOSURE CERTIFICATION FORM <br /> Psis a <br /> 9UalnE52 nAM S W.Celtt q. <br /> SIiE +ooRess <br /> tw <br /> W9.eii <br /> roS i rm <br /> i TA..ovm <br /> l ^WMC a. I <br /> i.nk OWNER eapRES9 1w <br /> j !)4t <br /> TUM OWNER Citt Sai STniE !eS bP tea <br /> Tank a Flammable vapor Oxygen <br /> (State Tank 100,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Almesphere <br /> Readings <br /> III r.FRTIFIrATjQN <br /> On examination of the tank.I ceniyPallomom product Sludge.Sale(thin.flaky residual of tank contents).fklseate and debris. I further certify <br /> Ret the infonnatbn provided hereine best of my knowledge. <br /> CERTIFIER SIGNATURESTATUS OR AFFILIATION OF CERTIFYING PERSON us <br /> CERTIFIER NAME(PRINT) see Certifier is a represemathre at the CUPMIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE wt <br /> Name of CUPAILIA <br /> ADORESS <br /> CITY If certifier a other Run CfIPAAJA chock appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIFQ <br /> DATE CEFITIF1ED soe N TIME ❑ CertRled Safety Profeaslonal(CSP) <br /> ❑ CertifiedMarine Chemet(CNC) <br /> ❑ Registered Environmental)Heats Soon let(RE)4S) <br /> ❑ Professional Engineer(PQ <br /> ❑ Gass It Registered Environmental Assessor <br /> ❑ CSLEI licensed contractor(with hazardous Substance certracate) <br /> ❑Yes ❑No Thu tank previousy,held Ilammabla ar combustible materials. If yes.the lank interior atmosphere shag be reelerxed with a combustible gas <br /> Indicator prior N work being conducted on the tank. <br /> Camaers tank management instructions for swap dealer.diapoaal)county,etc <br /> A copy of this certificate Shad accompany the tank to the mcyCingldisposat fodiry. <br /> V <br />