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r; <br /> TANK CLOSURE CERTIFIGATtON FORM <br /> b <br /> l <br /> ?aq� at <br /> ISI 1 FAGUTY ID• 1 <br /> BUSIHESSNAA/C <br /> SITF ADDRESS <br /> 2�,So <br /> aUsINE55 UrY <br /> los _77 <br /> J1 1�� so6 <br /> 'ANK Cw7rER NAME � /�Jj/t J . <br /> Q <br /> 501 <br /> 'ANK OW14U ADDRESS <br /> C� <br /> 5 <br /> 562 _ STATE SO 50A <br /> TANK OWNER CITY <br /> MW I C <br /> Tank x Flammable vapor Oxygen <br /> (State Tank It)$,if applicable) TOD Center Bottom Top Canter Bottom <br /> Tank Interior ./ D 3L5Rea /.� 0• d.� <br /> Atmosphere <br /> Readings <br /> �� /� !�/� pb3 . � �•� O• D 19. 3 <br /> Por <br /> 111 CER TIEV--ATION <br /> On examination of the tank,I certify the tank is visually free from product.sludge,scale(thin,flaky residual of tank.contenis),rinseate and debris. i further certify <br /> that the information provided herein i accurate a be wledge. <br /> CERTIFIER SIGNATURE el STATUS OR AFFILIATION OF CERTIFYING PCRSON art Sas i <br /> CERTIFIER NAME(PRINT) roe Certifier is a representative of the CUPA/LIAA YES ❑ NO - <br /> CE.RTIFiER TITLE 5o7 <br /> J• '12. �� Qi Name of CUPA/LJA <br /> ADDRESS'.' If certifiers other than CUPAJUA check appropriate box beknv; <br /> C:TY C <br /> PHONE AaD ❑ Certified Industrial Hygienist(CIH) . <br /> DATE CERTIFIED sos CERTIFICATION TIME C3 Certified Safety Professional(CSP} <br /> ❑ . Certified Marine Chemist(C%4C) <br /> ❑ Registered Environmental Health Specialist(RE:HS) <br /> ❑ Professional Engineer(PE) <br /> r❑ Cass II Registered Environmental Assessor <br /> �G CSJB licensed contractor(with hazardous substance certifipte) <br /> Yes ❑ No =, This tank previously held flammable or combustible snatenals. Jf yes.the tank interior atmosphere shalt be re-checked with a combustible gas <br /> indicator prior to work being condumed on the tank. <br /> Certifier's tank management instructions for scrap dealer,disposal faulty;etc <br /> I <br /> A copy of this certificate shalt accompany the tank to the recycingldisposa!facility. <br /> { <br />