Laserfiche WebLink
L <br /> j: <br /> TANK CLOSURE CERTIFICATION FORM <br /> Pop at <br /> r <br /> ,�-- Inr-NT1FIr.AMQN <br /> 3' PAOUTY iO s <br /> USINESS NAME <br /> ;y l0a <br /> SITE ADDRESS <br /> 105 aUSINFSS IIP 106 <br /> ,.USINBSS CITY <br /> 500 <br /> TANK OWNER NAME ./� �• /���+ _ <br /> r• �,V r7r�L��l�� <br /> Seo <br /> 14K OHMER AaORESS - <br /> x i1 <br /> 502 STATE 50 BP .. 50NA <br /> .ANK OWNER CI1Y �. . <br /> c C. <br /> T� • <br /> Flammable Vapor 0- <br /> Tank A Canter Bottom <br /> (State Tank IDS.if applicable) Top Center Bottom Tap <br /> Tank Interior <br /> Umosphere <br /> actings <br /> ii • <br /> 1 <br /> On examination of the tank.I certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank contents),rinseate and debris. I funxter Certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sos <br /> CERTIFIER NAME(PRINT) soa Cartifier is a representative of the CUPAILIA: YES U. NO 13 <br /> CERTIFIER TITLE Sar. Name of CUPAfUA <br /> ADDRESS if certifier is other Men CUPAILIA chedt appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> -PHONE ❑ Certified Safety Professional(CSP) <br /> DATE CERTIFIED sae CERTIFICATION TIME <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental health Speraatisi(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLS licensed Contractor(with hazardous substance Certr fcate) <br /> El Yes [3 No This tank previousty heid flammable or combustible materials. It yes,the tank interior atmosphere shall be re-checJted h a'combustible gas <br /> indicator prior to work being conducted an the tank. <br /> Certifiers tank management instructions for scrap deafer.disposal facility,str <br /> A copy of this certificate sh�'=,�panytank to the recydingldisposat facility. <br /> ( <br />