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TANK CLOSURE CERTIFICATION FORM <br /> 9OSINES$�A�E . <br /> 3 1 FACILITY 100 1 <br /> 0� <br /> SITE ADDRESS / 1M <br /> -o ( F- . cb "L"07 <br /> auslNEss CITY 105 euSINESS nP IN <br /> nK OWNER w.ME ,�^1 5m <br /> TANK OWNER ADORESS 501 <br /> TAt OWNER CITY 502 STATE %u DP SU <br /> Ar r, rec-« C-A 196733 46 <br /> Tank A Flammable Vapor Oxygen <br /> (Slate Tank IDS,if applicable) 1 Top Center Bottom Top Center Bottom <br /> Tank Interior LE L 7F o <br /> Atmosphere ' ' / 91 <br /> Readings [/ / <br /> III CPRTIFIrAnoN <br /> On examination of the tank,1 certify the tank is visually free from product sludge,scale(Nin,flaky residual of tank contenu),nnseate and debris. I further certify <br /> that the information provided ein is true and curate tD the best of knowledge. <br /> CERTIFIER SIGNATU STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CERTIFIER NAME(PRINT) sm Carifier is a representative of the CUPA/IJA: YES ❑ No Q <br /> CERTIFIER TITLE wr <br /> Name of CUPA/LIA <br /> ADDRESS C If certifier is other than CUPA/L1A check appropriate box below: <br /> CITY ❑ Cerdfied Industrial Hygienist(CIH) <br /> PHONE <br /> Certified Safety Professional(CSP) <br /> DATE CERTIFIED sm CERTIFICATION TIME Q <br /> ,'l> ❑ Certified Manne Chemist(CNC) <br /> o✓ `.Qo yo/+� ❑ Registered Environmental Health Specialist(REHS) <br /> ❑ Professional Engineer(PQ <br /> ❑ Class It Registered Environmental Assessor <br /> CSLS licensed contractor(with hazardous substance certificate) <br /> ❑Yes 13 No This tank previously held flammable or cembusdble matenals. if yes.the tank interior atmosphere shall be re-checited wdh a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifie`3 tank management instructions for wrap dealer,disposal facility,etc <br /> A copy of this certificate shall accompany the tank to the MCyCmydisposal fadity. <br />