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r <br /> TANK CLOSURE CERT1FICATtON FaRPA <br /> ' mss. ar <br /> BUSINESS NAME 3 FACtUtY ro v f <br /> CGS 2(n�-cr COr���ny . <br /> 3rW ACCn5S5 <br /> 1�7 Ido So(& Nu{ Ian C>J <br /> TANx=wCs'3v.snERN AMeLJ G+ r ray aLmmess uP 95 3 3 0 <br /> � <br /> TANK CHNER AOORE55 tai <br /> TwNx 4.vNER GTY *� STAT-. 303 I ap Sup <br /> lank m Flammable Vapor Oxygen <br /> (Slate Tank 104.if applicable) Top Center $ottorn Top Canter eattom <br /> Tank interior <br /> Atmosphere <br /> 1 0- J0- Z�. 2{ .C2v <br /> V -ST Q{ <br /> 7 <br /> 1U CERTIFICATION <br /> On examination of the tank.t certify the tank is visually free from product.sludge.Scale(thin.!laky residual of tank contents),rinseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of ray knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFMAT1CN OF CERTIFYING PERSON f s <br /> CERTIFIER NAME=(PRINT) sad Cartifter is a representative of the CUPA/LUL• YES ❑ NO ❑ I <br /> CERTIFIER TITLE 5a7 <br /> Name of CUPAAJA <br /> ACORE:SS <br /> If Cmelfter is otner than CUPArLLA check appropriate!sax bekw; <br /> CITY <br /> n NE ❑ CervSed industrial rlygienist(Cfl-f) <br /> CATs:CERTIFIED soa CErRT1F1CATICN 71ME ❑ Certified Safety Professional(CSP) <br /> Q Caftitted Mtanne Chemist(C.AC) <br /> © Registered Environmental Health Specialist(RF-HS) <br /> Q Professional Engineer(PE) <br /> 0 Class If Registered EnWonmentaf Assessor <br /> © CSLH licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑No This tank previously held flammable or comauslible materials. If yes.the tank interior atmosphere shall be re-checked melt!a cambtuabfe gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifrer's tank management instsucrtans for scrap dealer.d*=w facility,eta <br /> I <br /> A copy of this certificate shall accompany lite tank to the evcyc5n9ldisposzt facility. <br />