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r <br /> le <br /> 4 <br /> Fir ULWIT <br /> ELILA 1 11, <br /> TANK CLOSURE CE.RTIFIcAmN FQRm - <br /> Q3 OCT 29 PM S: 36 <br /> ai1SiNES3 NAME 3 iACtr.,tlr iR s , <br /> 11 lda SoU �af 44n Zo,& <br /> , BkSSiNEsi t,�rr f G�' r tos auswEss IIv q..� 3 3 0 '� <br /> TANK MME�R NAME I► { <br /> t f <br /> I TANK C`.M I18 ADCRESS I ` J 1 .q•� n 3D7 <br /> 00 S plJh F�GC�Gn S�Oc. <br /> rANKc..ms.RciV Sat SYwT'e SW AP I" <br /> LCA 9S 330 <br /> Tank s Parrnmabte Vaoar Oxygen <br /> (State Tank lt1,if appllrabie) Too Center eottom Top Center( Bonom <br /> Tank <br /> Atmasnherer ��. 2G. { t�0 , 9 <br /> p UST- L ,� <br /> Readings <br /> I <br /> On examination at the tank.I certitr th ank is visually tree from prcduC¢.sfudge.sole(chin.laky residual of tank Contents),rinseato and debris. I further caTtity <br /> that the informaften provided he 3119ccurate,1,9the best of my knowledge. <br /> G1;RTIFIER SfGNATURE STATUS OR AFFILIATION CF CERTIFYING PERSON <br /> CER T iFIE.R NAME(PRINT} roe kf b}� er Gr Cartiftef is a represent-aOve,c(the CUPA4.IA: YES ❑ ,N0 ❑ I <br /> CERTIFIER TITLE SOT �r Ura�we 9 C nr+ter n <br /> 5 . Name of CUPAAJA <br /> ACCRESS I(may'I LucrueLJQ if cer85er is other than CUPAA-IA check appropriate box below. <br /> CITY $ d ? <br /> FHCNE - O 1G (, Q Certtficd kwusalm Hygienist(C" <br /> DA i c C0MFiM sae C0-MFICA nCN TIME © Cadtfiied Safety Professional(CSP) <br /> 13 Cardllled fatalum Ctiemut(C.IAC) <br /> d — O D Q Registered Ernarbnawntal Health spectarmt(Reis) <br /> (• Q P+ofesiaunai Estglrueer(PEl <br /> © Ctass It Registered ErMconmental Assessor <br /> �. CSLa IicertsCd canerscxor(Witft tpy�rdairs sutsst7nce serttAoatel <br /> 0 Yes C3 No This tank previously held ftaenmabie or combuubte mamnalL it yes.the lank karfor almWptrem shale be re-cr diced Wim a cwnb&LWble gas <br /> indicator prtnr to work being candudted an the tank. <br /> CartiffeYs tank management insawcd=for srrsp dealer,disposal facility,etc <br /> - I <br /> } <br /> 1 <br /> A copy of this cenificate shall accompany the tank to the recyC•utgfdisposat t27Eitty. <br />