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FORM BFI EMPLOYERS CONFINED SPACE ENTRY CERTIFICATION AND SAFETY TRAINING OF EMPLOYEES To: Owner of underground storage tank designated below. Contractor's Name: Address: City State Zip Person in Office Responsible: Phone: Contractor State Approval Number: Contractor Approval Expiration Date: Location of Work: Contracting Company(Owner): Address: CityState Zip Phone: Person Authorizing Work Address of Work: City: State Zip Site Phone: Tank Size: Contractor's Authorization: Qualified person(Supervisor)on Location: Alternate qualified person(Supervisor): List of all employees that will be on the job: The above employees are qualified personnel, designated by the employer listed above as capable by training of anticipating,recognizing,and evaluating employee exposure to hazardous substances or other unsafe conditions in a confined space. The personnel are knowledgeable of the Material Data Safety Sheet disclosures as described in section A5. 1.7 of Chapter A on all applicable materials that may be used performing the work described in NLPA 631 and are capable of specifying necessary control and/or protective action to insure safety. I do hereby swear and attest that the above personnel have been trained and are familiar with NIOSH (Criteria for a Recommended Standard, Working in Confined Spaces Dec., 1979) and are knowledgeable of all the safety procedures contained in Chapter A. We/I, the employer, are maintaining written records of training, including safety drills, inspections, tests, and maintenance. The records are available for review by the State Implementing Agency or Owner,upon request. SWORN TO AND SIGNED THIS DAY OF ' 19 Witness Officer/Owner of Contractor Witness Title Page 1 of 2 49