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TANK CLOSURE CERTIFICATION FORM <br /> anon d <br /> 9USIMEES IMY / ] FACRITY Ip• I <br /> ]tiE applecee <br /> IM <br /> W&NES] <br /> o] 101 <br /> TAII1t O.W !L4 �y�, 500 <br /> I L� <br /> TANKo Ee AWRE]] bl <br /> //I �• <br /> iwMf OVME Citt SOx STATE SW DP � Sal <br /> m A- <br /> If TAWW <br /> Tank a Flammable vapor Oxygen <br /> (State Tank ION.if applicable) Tap Center Bottom Top Center Bortom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III C.PRTIFICATION <br /> On examination of the tank.I certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank Contents)•dnseats and debris. I further codify <br /> Mat the information provided herein i3 true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON raa <br /> CERTIFIER NAME(PRINT) we Certlfien is a representative of the CUPAIUA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sot. <br /> Name of CUPAAJA <br /> ADDRESS <br /> CITY If certifier is other diad CUPA/UA Check appropriate box below: <br /> PHONE ❑ Certified Industrial Hygienist(CIQ <br /> DATE CERTIFIED soa CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Gentled Marine Channel(CMC) <br /> ❑ Registered Environmental Heats Specialist(RE)IS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Gass 11 Registered EmAronmer"Assessor <br /> ❑ CSU3 licensed contractor(with hazardous substanm certificate) <br /> ❑Yes ❑No The tank prewoualy held dammabfe or combustible materials. If yes•the lank interim atmosphere shad be re-checked with a oombusdble gas <br /> Indicator prim to work being conducted on the unk. <br /> C2mear3 tarso management Instructions for scrap dealer•disposal fatality,etc <br /> A copy of till,certificate shad accompany the tank to me mcycling/dlsposat bnYfy. <br /> 1 <br />