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TANK CLOSURE CERTIFICATION FORM <br /> aq. a <br /> dU$IMfss MAME S FAC'11x 10• 1 <br /> _ G; T�__a� S 1 ;74r.11 17Y rr-NMFIrA'noN <br /> Tc%7.�J <br /> SriE 0a0.E55 <br /> / ,� lr EZae y < a. <br /> suslNessax C ' ,os auswfssa fZ0 <br /> Z <br /> Z,m <br /> TANK�V+nE'.t NAME 300 <br /> ' TANK U"hNfR A00RE55 91 <br /> TANK ERu "c srAr aR sd. <br /> f� Z <br /> Tanks Flammable Vapor Oxygen <br /> (State Tank IO2,it applicable) Tap Center Bottom Top Center do Rom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III (-.FRTIF;rATIQN <br /> On examination of the tank. I certify the tank is visually free from product sludge,scale(Nin,flaky residual of tank contents),nnseate and deans. I further certify <br /> that the information provided herein is true and accurate to the oast of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON scs <br /> CERTIFIER NAME(PRINT) soe Cardfier is a representative of the CUPAILIA: YES ❑ NO X' <br /> CERTIFIER TITLE <br /> Name of CUPAIUA <br /> ADDRESS <br /> CITY If certifier is other than CUPAAJA aleck appropriate box below: <br /> PHONE ❑ Cardfied Inde sMal Hygienist(CIH) <br /> DATE CERTIFIED sas CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Cnemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ C:=II Registered Environmental Assessor <br /> r�t Ld licensed comracror(with hazardous substance cenrticate) I <br /> aGhCes ❑No This tank previously held flammable or camousoble materials. If yes.the tank interior atmosphere stall be re-checked wAh a combustible gas <br /> indicator prior to work tieing conducted an the tank. <br /> Cartifiers tank management inswcdons for scrap dealer.disposal facrlity,etc <br /> A copy of this certificate shall accompany ale tank to the recyCinrydispasal facility. <br />