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TANK CLOSURE CERTIFICATION FORM <br /> B11&ME..A,YQ ., <br /> ere•ooAess ,e• <br /> -2- `i ;, <br /> wmrsss ur, .'5fsPC4d' MJ Ck4Ai1f <br /> roar ownae...R. >m <br /> TbM �✓9NS <br /> r.WI P'MEA.doaE59 nt <br /> r.n.a+eu utv m gran ria m so. <br /> rxr�N �A' `l T2o� <br /> Tank Flammable Fmnable V.W Oxygen <br /> (State Tars la.s appli axle) Too Center Bottom Too Center Bottom <br /> Tank Its. <br /> Atmosphere <br /> Reading. <br /> On e.aminaW of Me tank.I certify Me tank s vsuady free hem Predu altdge,scale(thin.Itaky raaiduei of tank tumem.l.nnaaap and debris. I kadwr ceNfy <br /> that Ne intgmadon Provided Main is due ants adaaatl W We Met Of my knowkMge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON fm <br /> CERTIFIER NAME(PRINT) ne fender la a nprefMltldye of ma CUPAhL.: YES ❑ NO ❑ <br /> CERTIFIER TITLE nr Name of CUPAAJA <br /> ADDRESS H mrdfW s ods r Men CUPAAJA tasta:apWopftW boa MWm: <br /> CITY ❑ Censded lndtsbisi N'!Gle^st(CW) <br /> PHONE <br /> DATE CERTIFIED m CERTIFICATION TIME ❑ cwww LWy Praltls ei(csP) <br /> ❑ CanMed MMkla Chsimst(CMC) <br /> ❑ Repi.Wad Em wmwW Heamt Spetaakat(RENS) <br /> ❑ Pmfanionei egnser(PE) <br /> ❑ Csaa II Regstare l EmitansrlW Assessor <br /> C3 CS.Im"d Mnbatam("M 1=101GW WMtance WWotl) <br /> Tike tens,prw uiy Ives flammable or comW Wds matanW. It Tell.tale M, ,sor Ww 'M <br /> aOna.PMm.Ma M nAedN m <br /> a motsdble Sae <br /> ❑Yaa [2 No yglobr prior W wars being cond,lCed on Me tank. <br /> GWflKs tank INr1VJe11411i k1amICI0I1e for soap deeier.dspoeal fatality.eic <br /> A copy of tea Ndnta sisal s000rnpany ds tank W ds mc/dIndt leW.al bdit <br />