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TANK CLOSURE CERTIFICATICN FORM <br /> i F I <br /> BUSINESS VAMC 3 I FACIUTY 10 s 1 <br /> SITE ACORESS 104 <br /> BUSINESS CITY 105 aUSINESS IIP :06 <br /> TANK CWNER NAME a00 <br /> TANK OWNER ADORESS - 5ol <br /> TANK OWNER CITY $02 STATE 503 1 BP 504 <br /> 11 LANK C1 051 IERE NEORMADO <br /> Tank Flammable Vapor Oxygen <br /> (State Tank IC*,if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> t I <br /> I <br /> On examination of the tank.I certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank contents),nnSeate and aeons. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFIL!ATiCN OF CERTIFYING PERSON hos i <br /> CERTIFIER NAME(PRINT) Sae Cartifier is a representative of the CUPA/UA: YES Q NO Q <br /> CERTIFIER TITLE soy <br /> Name of CUPAA IA <br /> ADDRESS If certifier is other than CUPAAJA check appropriate box below: <br /> CITY Q Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED so® CERTIFICATION TIME Q Certified Safety Professional(CSP) <br /> Q Candied Marine Chemist(CIRC) <br /> Q Registered Environmental HeaRh Specialist(RENS) <br /> Q Professional Engineer(PE) <br /> Q Crass it Registered Environmental Assessor <br /> Q CSL8 licensed contractor(with hazardous substance certificate) <br /> Yes Q No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shad be re-Checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> I <br /> j A copy of this certificate shall accompany the tank to the recycingidisposal facility. <br />