Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br /> a PAQUIN10. t <br /> a1151NE55 NAME <br /> Shc�.wvcr ?YUP�4'J <br /> M <br /> SITE ♦ODRESS <br /> q I b N Br ad wa <br /> eUSINEa$CITY � to5 aUSiNE5321P tte <br /> TANK CwMElt NAME SW <br /> Game,- <br /> TAMC CNMER ADDRESS �1 <br /> TANK C+•/NER GTV SPS STATE SOa AP 5W <br /> T <br /> Tank S Flammable Vapor Oxygen <br /> (Slate Tank IOt.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> I <br /> III rF=RTIFIrATIQN <br /> On examination of the tank.I certify the tank is visually free from product sludge,sole(min,flaky residual of tank writer=)•rinseate and debts. I hasher certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON xs ' <br /> CERTIFIER NAME(PRIN-n Soe Certifier is a representative of the CUPA/UA: YES ❑ NO Q <br /> CERTIFIER TITLE SOT <br /> Name of CUPAnJA <br /> ADDRESS <br /> It ortifier is Omer than CUPA/LIA Cheat appropriate box belpw: <br /> Cm <br /> PHONE Q Carded Industrial Hygienist(CIH) <br /> DATE CERTIFIED soe CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> Q Certified Manna Chemw(CMC) <br /> ❑ Registered Environmental Health Specialist(RE:—S) <br /> ❑ Professional Engineer(PE) <br /> Q Crass II Registered Environmental Assessor <br /> ❑ CSLS licensed Contractor(With hazardous substance Certificate) <br /> ❑Yes ❑No This tank previously ned flammable or combustible materials. If yes.the Lank interior aurimpnere snag be re-sheeted wdh a combusuble gas <br /> indicator prior to work being conducted on the tank. <br /> CarifleYs tank management instructions for scrap dealer.disposal facility.etc <br /> A cooy of this CCnificate snag aCCompany the tank to me recycinWiliscosal fa Glity. <br />