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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME C 6 FACILITY KJ• + <br /> w <br /> yTE ADDRESS <br /> Z 85 p til -Si Kron 9-5ZQ5 <br /> BVSINE55 C:TYtoe BUSINE53 DP <br /> 5 TCN <br /> TANK CVVWU NWE SW <br /> TANK OWNER ADDRESS SOS <br /> Z Cr c le <br /> TANK OWNER CITY 502 STATE 561 I bP 56• <br /> S io <ZO 52F--7 <br /> -7 11 IAUK 91 QqI IPP INF:QPMA-nQbj <br /> Tank f Flammable Vapor Oxygen <br /> (Slate Tank iD*.if applicable) Too Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rFRTIFI('ATI(')NI <br /> On examination of the lank. I certify the tank is visually free from product sludge,scale(thin,flaky residual of tank contents),rinseate and Debris. I further certify <br /> that Ue infomtation provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON soa <br /> CERTIFIER NAME(PRINT) 506 Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE Sm <br /> Name of CUPA/LIA <br /> ADDRESS <br /> It cenifier's other than CUPAILIA check appropriate box Debw: <br /> Cm <br /> PHONE ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED 508 CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Crass II Registered Environmental Assessor <br /> ❑ CSIB licensed contractor(with hazardous substance certificale) <br /> ❑Yes ❑ No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> Indicator prior to work being conducted on the tank. <br /> TI Canifiefs tank management instructions for soap dealer,disposal faelity,etc <br /> �I{ <br /> I <br /> A copy of this certificate shall accompany the tank to the retyding/dispotu l facility. <br />