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:NK CLOSURE CERTIFICATION ECRM <br /> hw x <br /> F — — <br /> auslNESs <br /> S '•ACIUTY10. <br /> >nE ADDRESS ' <br /> to <br /> ausiNEss CITY <br /> 105 ausiNESS L'P its <br /> TANK eft NAME <br /> 500 <br /> TANK CA srt A00RESS <br /> 901 <br /> TANK d'm+ER C,T <br /> 503 3TATE 90] I bP Spa <br /> nmu r 1 Q <br /> Tank i Flammable'✓aoor Oxygen <br /> (Slate Tank 100,i(appiirrDle) Top Center Bottom Top Center Bottom <br /> Tank ritenor <br /> Atmosphere <br /> Readings <br /> III C,'E2TIF;CA71QN <br /> On examination of the tank. I Certify the tank is visually free frac, oroducL sludge.scale(thin,flaky residual of tank comems),rinseate and deans. I further certify <br /> that the Information provided herein is true and accurate to the ocst of my knowledge. <br /> CERTIFIER SIGNATURE 1 <br /> STATUS OR AFFILIATION OF CERTIFYING P-RSCN sas <br /> CERTIFfER NAME(PRINT) sce <br /> CcRTIF1ER TITLE'9o7 - , Cartifier is a representative of the CUPAUA: YES Q NO Q <br /> ACORESS � Name of CUPA/LIA <br /> 70A7ECERTTFIED <br /> If certifier s other than CUPAlW1 check appropriate box below: <br /> Q Cenffied Industrial Hygienist(CIH) <br /> son CERTIFICATION I,mE ❑ Cartified Safety Professional(CSP) <br /> ❑ CarVfied Marine Chemist(CMC) <br /> ❑ Registered Environmental Heaeh Specialist(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLS licensed contractor(with hazardous substance t r ifirate) <br /> ❑yes ❑ No This tank previously held flammabfe or cr.:uusDDle materials. if yes.the lank interior annosphere shall be radtecked with a combustible gas <br /> Indicator Prior to work being conducted c:. r,e tank <br /> Cartifler's tank management instru Pons for scrap dealer,disposal facility,etc: <br /> A copy of this cartificam ;nail accompany the tank to the recycing/disoosal facility. <br />