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TANK CLOSURE CERTIFICATION FORM <br /> I ire <br /> to 3 FACIuTY M• <br /> U9HESS KAME <br /> Ir <br /> t0+ <br /> WTE 100RESS <br /> bSINESS a 1 <br /> BU "1 ,os 3USINFSS LP + 05 <br /> (3`4 1 l <br /> 500 <br /> TAW CWwE A r"ME <br /> U ; P 1 SD, <br /> TA ER ADDRESS <br /> 502 STATE S03 c7p/� �'` <br /> W-AM,['J YNE�C�� <br /> I <br /> Tank s Flammable Vapor Oxygen <br /> I I (State Tank 1; if applicable) Too Center Bottom Top Center Bortom <br /> l <br /> Tante Interior <br /> AtMCspnere <br /> Rea itngs <br /> l <br /> lit 1-cm-nCli" <br /> On examination of the tank 1 certify the tank is visually free from product sludge scale(thin flaky residual of tank contents),nnseate and aeons I further certify <br /> that he Information provided herein Is true and accurate to the best of my knowledge r <br /> CERTIFIER SIGNATURE <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CERTIFIER NAME(PRINT) Sod Cartifter is a representative of the CUPAIUA YES ❑ NO ❑ <br /> ' G=RTIF,ER TITLE sor Name of CUPAJLIA <br /> ADORESS If cartifler Is other than CUPA/UA ch*cK appropriate box below <br /> CITY ❑ Cerofled Industrial Hygienist(CIH) <br /> PHONE ❑ Certified Safety Professional(CSP) <br /> DATE CERTIFIED soa CERTIFICATION TIME <br /> ❑ Certttled Marine Chemist(C-MC) <br /> ❑ Registered Environmental Health SpeaaW(REI-1S) <br /> s <br /> Professional Engineer(PE) <br /> ❑ Class Il Registered Environmental Assessor <br /> ELS' CSL$Iiartsed contraCtor(with hazardotu substance certificate) <br /> "es C] o- <br /> No This tank previously held flammable or combustible matenals if yes the tank Interior atmosphere shall be rctteciced with a combusbble gas <br /> indicator prior to work being conducted on the tank. <br /> I <br /> S Cantfiers anx management Instrucdons for soap dealer dispo"faaltty,etc. <br /> i <br /> I <br /> A copy of this certificate shall accompany the tank to the recychngldisposal faalrty <br /> J <br />