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:a <br /> `k4 <br /> TANK CLOSURE CERTIFICATION FORM <br /> rk» <br /> aus ESS CITY i 105 aUSINESS ZJP d•06 <br /> G--� <br /> DANK C 5W9 NAYS .. <br /> G i <br /> Peat 0%%NER ACMESS 'ot <br /> TAtNk OwvnER aTv 502 STATE 503 � 50+ <br /> 2 <br /> Tank A" Rar-mable Vapor Oxygen <br /> (State Tank toe.if applicable) Top :enter Bottom Top -Center Sadom . <br /> AT Interior <br /> / ®D • 0G '06 <br /> Readings <br /> III CERIIEr 1110W <br /> On examination of the tank.I certify the tank is vesually free from product.slUdge.scale chin.flaky msiduai of tank contents).mmate and debris. i Stutter certify <br /> that the information provided herein is of my knowledge. <br /> CE.RTIFiER SIGNATURE T ATUS OR AFFILIATION OF CERTIFYING PSRSCN sos <br /> CERTIFIER NAME tPRi r :artfier is a tine of the CUPA/UA: YES Q NO <br /> CERTIFIER TITLE so> <br /> name of CUPAAJA <br /> ACCRESSC.-,5•9 IZ f certifier is otter than CUPMJA check appropriate box below: <br /> CITY I Q Certified I Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED CERTIFICATION TIME Q PO10nal(CSP) <br /> Q Certified Marine Chemist(CMQ <br /> Q Registered amiromnental Hue Specialist(REHS) <br /> ! 0,_3 <br /> r J 0 Q P Engineer(PE} <br /> ff Q Gass it Reglistered Envirmiriental Assessor <br /> CSL8 licensed conttaactor(with hazardous substance carbficate) <br /> Yes Q No This tank halo fhunmole or combustible materials. f yes.the tarok inteasff shay be re-checked with a combustible gas <br /> indicator prior to work bang candtrded on the tank. <br /> Cartifiers tank management instructora for scrap dealer.diapasal factily.etc <br /> A copy at this certificate shalt accompany the tank to the recycing/dispasal facility. <br />