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TANK CLOSURE CERTIFICATION FORM <br /> � — d <br /> Bl161YE5511AY� � � � FAGUTY IO• , <br /> SriE a00RE55 <br /> -2 / <br /> WS1YES5 CITY l ,as au5ill v ,oe <br /> TA O'AMEA NAY. ` Sm <br /> BOLL <br /> TAIek pvMER wpptFSS <br /> 5p1 <br /> TAMC Q ER CrrY — 5@ STATE ses ➢F SW <br /> It TANK I QSLJgRjF_: IN;:MQKAATIQN <br /> Tank A clammable Vapor Oxygen <br /> (State Tank IDt,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior ,r) <br /> Atmosphere <br /> Readings <br /> L <br /> III CPR7IFIrATIQN <br /> On examinabon of the tank.I certify the tank is visually free from produG sludge.scale(thin,flaky residual of lank contents),rinseate and debris. I further certify <br /> that the information provided herein isno rale the best of my knowledge. <br /> Ree—, <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON ads <br /> CERTIFIER NAME(PRINT) sof IW�f (I Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑. <br /> CERTIFIER TITLE sar <br /> Name of CUPA/UA <br /> ADDRESS �(f, �G/C /{ r ' <br /> If certifier is Omer than CUPAILIA C,eUc appropriate box below: <br /> Cm ZK . <br /> PHONE <br /> ElCertified IrMtestr®1 Hygienist(CIH) <br /> Certified Safety Professional(CSP) <br /> DATE CERTIFIED sts CERTIFICATION TIME <br /> ❑/ <br /> ❑ Certified Marine Chemist(CMC)0 0, <br /> ��� �J ❑ Registered Emnronmenul Heats Spedalisl(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ less <br /> II Registered Environmental Assessor <br /> L9 licensed contractor(wdh hazardous substance Certificate) <br /> y�„es ❑No This tank pmwousty,held flammable or combustible materials. If yes,the tank interior atmosphere shall be re•droticed wdh a combustible gas <br /> ;"� indicator prior to work being conducted on the tank. <br /> Cwtifiers tank management instructions for scrap dealer,disposal facility,eta - <br /> A copy of this certificate shall accompany the tank to the recyciing1disposal facility. <br />