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TANK CLOSURE CERTIFICATION FORM <br /> �•o• d <br /> F <br /> s I r+uu7v io• + <br /> C C .T <br /> AoortEss <br /> / L SM-60 CITY <br /> 501 <br /> M OvwEA f3tY 5@ arA Soa clP Set <br /> Sip GXT•,1 9y�2 o2- <br /> Tank 0 Flammable Vapor Oxygen <br /> (St-!e Tank IDs.if applicable) Top Center Bottom Top Cemex I Bottom <br /> nk Interiori <br /> Mach" L)L� '06 106 D <br /> ndings <br /> [I[ rFIR71FIrATION <br /> n examination of the tank.1 certify the k is visually m produm sludge.scale(thin,flaky resOual of tank coram),mLseate all aeons I fuller ce�`y <br /> at the intonnation Pmt herein" best of my knowledge. <br /> ERTIFIER SIGNATURE y- STATUS OR AFFILIATION OF CERTIFYING PERSON sss <br /> ERTIFIE NAME(PRINT) , / Certifier is a representative of the CUPAILIA: YES [2 NO Q <br /> ERTIFIER TITLE em <br /> Name of CUPAILIA <br /> DORESS _ - �R If certifier 6 other than CUPAILIA check appropriate Iwx below: <br /> MY <br /> ❑ Certified Industrial Hygienist(CIM) <br /> HONE f( <br /> ATE CERTIFIED sca CERTIFICATION TIME ❑ Cemfiea (�P) <br /> ❑ Certified Markle Chemist(CMC) <br /> j ') 10310 <br /> �/" ,r ❑ Registered Ems mn"Ontal Health SPedaGst(RETS) <br /> Ole /yam / ❑ Professional Engineer(PE) <br /> ❑ C:aw II Registered Emdroninenfal Assessor <br /> CSLEI licensed contractor(wah 111123MOUa substance certificate) <br /> Yea ❑ Na Thus tank Previouslymm <br /> held flat or combustible matenals. If yes.the tank interior atmosnag phere sbe re-d,edted wdh a mmousbbIs gas <br /> mditator prior to work being mrtlucted on the tank <br /> �amfierS tams managernem insduccons;for asap dealer.disposal facility.ate <br /> A copy of this camficate snail accompany the tank to the recyc ing/cImposal facility. <br />