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TANK CLOSURE CERTIFICATION FORM <br />BUsiwEss ruwF C <br />C <br />a <br />cAGUTY poi r <br />SrTE +DDRESS <br />ci I J N <br />BUSINESS UT' STO TD N <br />;05 <br />dUS�NEc ^ '1 G ;Dd <br />TANK D tVt NAME t <br />s� <br />T <br />TANK DY✓NER ADDRESS <br />5pT <br />I �c I Ro <br />o a <br />TANK Cw ER CITY <br />502 <br />STATE 50a <br />bR SW <br />To C <-ToPll <br />cff <br />1,152fj-7 <br />C <br />Tank S <br />Flammable Vapor Oxygen <br />(State Tank ICS, if applicable) <br />Top <br />Center Bottom To <br />Center <br />Bottom <br />{ Tank Interior <br />Atmosphere <br />Readings <br />III f.FRTIFIrATI0N <br />On examination of the tank. I cenity the tank is visually free from product. sludge, sole (thin, flaky residual of tank comems), rinseate and aeons. I further certify <br />that the information provided herein is Ime and accurate to the best of my knowledge. <br />CERTIFIER SIGNA T URE <br />STATUS OR AFFILIATION OF CERTIFYING PERSCN sn5 <br />Certifier is a representative of the CUPAA.iA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRINT) son <br />CERTIFIER TITLE soT <br />Name of CUPA/LIA <br />If certifier 's other than CUPA/LlA cnedt appropriate box Debw: <br />El Certified Industrial Hygienis11C1H) <br />[I Certified Safety Professional (CSP) <br />ADDRESS <br />CITY <br />PHGNE <br />DATE CERTIFIED sod <br />CERTIFICATION TIME <br />❑ Certified Manne Chemist (CMC) <br />❑ Registered Environmental Health Spedalist (RE-iS) <br />❑ Professional Engineer (PM <br />❑ Cass; It Registered Environmental Assessor <br />• <br />❑ CSLS licensed =,,,aor (with h=ardous substance certrfiote) <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />It yes, the lank interior atmosphere shall be rechecked with a combustible gas <br />indiolor prior to work being conducted on the tank. <br />r Cartifier's lank management instructions for soap dealer, disposal fadlily, etc <br />I <br />A copy of this cer ifiote shall accompany the tank to the recyCing/disposal taolrty. 7 <br />