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' k <br /> TANK CLCSURE Cc TiF?C,;TICN FORM <br /> 'law <br /> 3U5IN NA Err_ 1 <br /> t �t <br /> S' FAGUTY i0 r <br /> SiTE.oasrl 2 n 3 q� <br /> �&(0� Z-0aen r5 <br /> 3uslN6a.a CnY G <br /> 105 aussTyyd�ss <br /> 5 P :oe <br /> rANx CNaNER <br /> sw <br /> —TANK CNNE,7-108R-1:Q1S <br /> l�. ►Jc7J� �JU`f'c1 D cJ�7�r-- C1Q- �� cj ��-- �d f <br /> -'AW WNER CITY ]7� <br /> SOS STATE 567 I QP 9a•a <br /> i A f f <br /> Tanks Flammable Vacor ' <br /> OxYgen <br /> (State Tank lf .if applitaale) Top Canter Bottom Top Center Scrtcm <br /> Tank Interior <br /> Atmosphere <br /> Readings t ✓ <br /> 4 <br /> On examination of the tank, f Cerdty the tonic is visuaily free from product,sludge,sole(thin,flaky residual of tank contents),rinseate and aecris. i further certify <br /> Char the rnformatfon prowdeC herein is true ana accurate to the best of my knowledge. <br /> CERT FiE,�j{GVATURE S7A7US OR AF=iLIA71CN OF CE�T1F!tNG PERSCN Sas <br /> CERTIFiE.R NAME(PRINT) sae I <br /> Cartlfier is a representative of he CUPA/l lA: YES ❑ NO ❑ <br /> CE.RT1FiER T I i LE <br /> Name of Ct1PAlUA <br /> ACCRESS <br /> CIT! If c2rtfier Is other than CUPAlUA Check appropriate box Celaw: <br /> PHCNE ❑ Cerafied Industrial Hygienist(CIH) <br /> DA e CERTIFiFr] ma CERTIFiCAilON TIME ❑ Carded Safety Professional(CSP) <br /> ❑ Certified Marine C:temmt(C.YIC) <br /> ❑ <br /> Registered Environmental Health SpecalLst(RE-?S) <br /> ❑ Professional Engineer(PE <br /> C Class tl Registered Environmental Assessor <br /> ❑ CSL6 licensed couwaacr(with hazardous substance certificate) <br /> ❑ Yes [( e materials. If yes,the tank fnterior gMcsphere shall be re-a`secked wdh a combustible gas <br /> No 7iits tank pre'viausty held flammacle or cambtrsa6l <br /> indicator prior to work being rmnduced an the tank. ` <br /> i rl <br /> Carafiets tank management instrucdoms for soap dealer,disposal fadW.eta t <br /> A copy of this certificate shall accompany the tank to the reclCing/dispasal fadlity. ! <br />