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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NUAE 3 FwVUTYio• t <br /> sTE,OCAEW -Y� <br /> I , <br /> ws,NEsa cln ,os a neJ. W <br /> iANItC EA INME !M <br /> 1 TAwf CM+EA w00AE55 30, <br /> Vo <br /> TwNN CMIEA UTY !OZ sTwTE SWP !N <br /> SIS 8 3 <br /> Tanks Flammatle Vapor Oxygen <br /> (State Tank IDS.if applicable) Top Center Sattom Top Center ednom <br /> Tank interior _ <br /> Atmosphere <br /> Readings <br /> Ill r.FRTIFIrATIQN <br /> On examinaton of the tank.I certify the tank is visually free from product.sludge.scale(Nin.flaky residual of tank contei rinseate and debris. I further ceni(y, <br /> that the information provided herein is We and accurate to the best Of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sa <br /> CERTIFIER NAME(PRINT) 50e Certifier is a representative of the CUPAAJA: YES ❑ NO Q <br /> CERTIFIER TITLE sur <br /> Name of CUPA/LIA <br /> ADDRESS If caroller is other than CUPA/L1A chetlr <br /> CITY apPropriste box below: <br /> PHONE ❑ Certified Industrial Hygionist(CIH) <br /> DATE CERTIFIED sea CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemet(CMC) <br /> ❑ Registered Environmental Health Specialist(RETS) <br /> ❑ Professional Engineer(PET <br /> ❑ Cress If Registered Environmental Assessor <br /> ❑ CSL9 licensed contractor(with haZardbus substance certificate) <br /> ❑Yes ❑No This tank previously held flammable or combustible materials. If Yea.the tank Interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cardflars tank management instructions for scrap dealer.disposal facility.etc: <br /> Aw►Y of hu certificate snarl accompany the letire cyC ray itis► al facility. <br /> 1 <br />