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YANK CLOSURE CERTIFICATION FORM <br />Tank Interior <br />Atmosphere <br />Readings <br />Tank # <br />(State Tank 100, if applicable) <br />Flav mable Vapor Oxygen <br />euslNEss NAME � / <br />/ e , <br />r- <br />rAClury io a , <br />SITE ADORESS <br />eo21mc,,J <br />104 <br />767 fi <br />BUSINESS CITY j <br />ADDRESS E d9 <br />toy <br />dUS1NE5S 2P <br />TANK OWNER NAME <br />PHONE A <br />5W <br />TANK OWNER AOORESS <br />❑ Certified Safety Professional (CSP) <br />501 <br />/ <br />otx <br />® Registered Environmental Health Specialist (REfiS) <br />TANK OWNER CITY <br />❑ Professional Engineer (PE) <br />SM <br />STATE S03 <br />I IIP 504 <br />Tank Interior <br />Atmosphere <br />Readings <br />Tank # <br />(State Tank 100, if applicable) <br />Flav mable Vapor Oxygen <br />Top :enter Bottom Top <br />tenter <br />Bottom ` <br />';arttfier is a representative of the CUPA& A: YES ❑ NO ❑ <br />CERTIFIER TITLE w t <br />name of CUPAILIA <br />ADDRESS E d9 <br />CITY ' <br />f certifier is other than CUPA/LIA check appropriate box below: <br />PHONE A <br />❑ Certified Industrial Hygienist (CIH) <br />DATE CERTIFIED s& CERTIFICATION TIME ; <br />❑ Certified Safety Professional (CSP) <br />j <br />❑ Certified Marine Chemist (CMC) <br />® Registered Environmental Health Specialist (REfiS) <br />❑ Professional Engineer (PE) <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 Rutter certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />>TATUS OR AFFILIATION OF CERTIFYING PERSON sos <br />CERTIFIER NAME (PRINT) sae /Z r <br />';arttfier is a representative of the CUPA& A: YES ❑ NO ❑ <br />CERTIFIER TITLE w t <br />name of CUPAILIA <br />ADDRESS E d9 <br />CITY ' <br />f certifier is other than CUPA/LIA check appropriate box below: <br />PHONE A <br />❑ Certified Industrial Hygienist (CIH) <br />DATE CERTIFIED s& CERTIFICATION TIME ; <br />❑ Certified Safety Professional (CSP) <br />j <br />❑ Certified Marine Chemist (CMC) <br />® Registered Environmental Health Specialist (REfiS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />" <br />CSL8 Iicensed contractor (with hazardous substance certificate) <br />Yes ❑ No This tank previously held flammable or combustible materials. <br />f yes. the tank interior atmosphere shalt be with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Cartifiets tank management instructions for scrap dealer, disposal facility, etc <br />A copy of this certificate shalt accompany the tank to the recyciing/disposal facility. <br />