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i <br /> TANK CLOSURE CERTTFicA-ncN FARM <br /> l =ar,,Il iTy ir_)pNTjF=irA-inN <br /> SS HAM[d t.`� � SZ�I a Ac:urr•o• r+77_ ' <br /> -7 �7 <br /> 33 C:T'/ / ��(/�^ � _ _ ���,Ac 'OS � 9US�NESs:P •a6 <br /> SER.4Aru`E--7'rl.�G <br /> .v+E;q AOORE>5iot <br /> p-�0 t j <br /> :mER CTS .Z � 5= I STA:e JW I zP 5OA <br /> If Ta (71 QSItJNE--)PMAT-XItj <br /> Tank s j Flammable vaporOxv,en <br /> _ <br /> (State Tank It*.if accticabte) Tao Canter 9onem loo j Canter j 3ortom <br /> 95rf - � I � �% I ,-gal � 0/o I f,S- q. / L <br /> I I ( I I I <br /> amination of the tank.I certfy the tank is visually free ham product.atudge.stale(thin,laky residual of tank contentsf,nnseate and aeons. t furmer certify <br /> s information provided herein is true and ac-,.nate to the best of my knowledge. <br /> FiE.R SIGNATURE ST ATUS OR AF=?L:A T ICN OF CE.=MFnNG PERSCu sos <br /> FIER NAME(PRINT) ioe Cartitfer is a representative of the C•JPA/UA: YES Q `t0 Q <br /> F;ER TITLE e07 <br /> 61ffir_ Name of CJPA/L'A <br /> ESS t <br /> tf certifier is other than CUPAlUA Ctedt apomonate box below: <br /> LCA !EQ Carded industrial Hygienist(CZq <br /> c -1r Q Carded Safety Professional(CSP) <br /> CBRTiFtF� sas CcRT1FiC.t.TiCN TIME <br /> Q Cartiffed Mature GSetrnst(C= <br /> Q Registered E;tvvonmemal Health Soecatist(RE—�S) <br /> gt/® f i fJ Q Professionai r-.igineer(PIE! <br /> Q Crass it Registered Environmental Assessor <br /> ^LB rinsed cormaeor(w+th na=rcous substance certificate) <br /> No i his tank-reviousty held flammable or combustible matenats, It yes.-he tank interior atmosphere shad � <br /> be c tecced wtth a combustible gas <br /> s indicator Prior to worts being conducted on the tank. <br /> ars tanx management ins�trucWnss for scrao dealerr,,�discosat faclity,etc <br /> A copy of this cemfitate snail act:moany{rte tanx:o the rec c:!nq/dJsoosat fac ity. <br />