Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br /> aiaiME55 MRME ^ L � ] FAGUT'ID• 1 <br /> SME ADDRESS l tM <br /> 2 4/ / , L � <br /> aUSWESS GTv <br /> TAM(DemER rurE �e7 L 5W <br /> O <br /> TA DNMER A,xxnFse San <br /> Tue(OwNElt T — = STATE ]W Do SlM <br /> G ,J <br /> Tank i 9ammable Vapor Oxygen <br /> (State Tank IDs.If applicable) Top Center Bottom Top Center Bottom <br /> Tank interiorre <br /> ReadinAtmosps n©C7 <br /> eaeingG/ <br /> III rFR71FIrATION <br /> On examination of the tank,I certify the tank is visually free from product sludge.scale(thin.flaky residual of tank contents),m seats and debns. I hab,er oar* <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 ]os <br /> CERTIFIER NAME(PRINT) SDa i¢Z T, Q Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑. <br /> CERTIFIER TITLE zar <br /> 7� Name of CUPA/LIA <br /> ADDRESS <br /> If cerafier's Omer than CUPA/LIA check appropriate box below: <br /> CITY ❑ Co.it Industrial Hygienist(CIH) <br /> PHONE <br /> LUTE CERTIFIED s CERTIFICATION TIME ❑ Camiked Safety Professional(CSP) <br /> ❑ Certified Manna Chemist ICMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ II Registered Emmonmemal Assessor <br /> P�SU5 licensed contractor(with hazardous substance certificate) <br /> ❑Yes ❑ No This tank previously held flammable or combusaille materials. If yes.the tank interior atmosphere Shall be re-citeG(ed with a combustible gas <br /> indicator prior to work hemp conducted on the tank. <br /> CentiTiefs tank management inidn]otons for soap dealer,disposal facility,etc <br /> A copy of this certificate shall accompany the tank to the recychng/disposal facility. <br />