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TANK CLOSURE CG TtFICATICN FORM <br /> ( C r <br /> :FessNAwc s � �Aautro.n. <br /> : .ocas� <br /> lo+ <br /> b . <br /> ;IIIc$$�t1Y ® 103 jI.SINe$, LP /� lag <br /> 6./ <br /> .N C'/I.N Fj7,`UME q a� <br /> aX M+E?ACCAE..S y01 <br /> 0 Sax 8 g® XaC <br /> R a,•Mea_.-Y <br /> sa I <br /> Tank 2 Flammacle Vaaor Oxygen <br /> (State Tank ICs.if applicaole) Too Center Bottom Top Canter Bottom <br /> nk Intenor <br /> resanere <br /> •adYRg: 1 <br /> L 1 —7— <br /> I <br /> I axammatien of the tank,t certify tate tank is visual)y froe from product.Sludge.scale(thin,laky residual of tank contents),rinseate and aeons. 1 further certify <br /> It the information provided herein is trio and accurate to the oest of my?utowledge. 1 <br /> :ATIFIER SIGNATURE STATUS OR AF;-ILLATION OF CERTIFYING PSRSCN Sas <br /> :?T(FIEA NAME(PRINT) soa Cartifler is a representative of the CUPAIUA: YES Q NO Q <br /> :RTIF;ER TITLE sot <br /> Name of CUPAILLA <br /> IoRess <br /> CY 5 &429 If certifier is anter titan CJPAJI.LA Ctedt aparoptiate oox oelow: <br /> -CNE CIO - 3 Q Cartiffed Industrial)iyglennst(C)N) <br /> ITr CBRTIFtEO Sas C—=RTIFICATION TIME ® Cartftfed Safety Profesaiana!(CSP) <br /> Q Cardfled mwne Cheam(C:4q <br /> ® Registered Environmemai Healm Soe=kt(RAS) <br /> Q Professional Engineer(171-2) <br /> Q Gass it Registered ErnironmenEat Assessor <br /> log CSLS licensed=naacoe(vntn nazzmaus substance cemflcate) <br /> yes ❑ No T his tank previously held flammable or comousstole materials. If yes.the mnk interior wmc3ahem Shall be re-dtecked-iM a combustiale gas <br /> indicator prior io went oelog conduced on the tsnk- <br /> mflers tank management instructions for scmo dearer.diaaosar facility,etc <br /> A ce0y of alis certificate shaft accomoony the tank to the recyC Vdisooaat facility. _� <br />