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TANK CLOSURE CERTIFICATION FORM - <br /> 9USINE55 N.�M 1 FACILITY IDS 1 <br /> SITE ADDRESS _ 1� <br /> i <br /> NO <br /> BUSINESS CITY IN BUSINESS LP IN <br /> TANK CwNER NAME 500 <br /> TANK DYMER ADDRESS Sal <br /> TANKp WNEft C�I]]'�' 503 STATE 50] DP SW <br /> IV( (a7tiCr� � <br /> Tank x Flammable Vapor Oxygen <br /> (Stale Tank ID#, if applicable) Top Center Bottom Top Center Bodcm <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rF:RTIFIrAT1nN <br /> On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin, naky residual of tank contents), rinseate and debris_ I further certify <br /> that the information provided herein is We and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON eos <br /> CERTIFIER NAME (PRINT) sea Cartifier is a representative of the CUPA/LIA: YES Q NO Q <br /> CERTIFIER TITLE wi <br /> Name of CUPA/LIA <br /> ADDRESS <br /> If certifier is other than CUPA/LIA cited( appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist (CIH) <br /> PHONE <br /> DATE CERTIFIED sae CERTIFICATION TIME ❑ Certified Safety Professional (CSP) <br /> ❑ Certified Marine Chemist (CMC) <br /> ❑ Registered Environmental Health Specialist (RENS) <br /> ❑ Professional Engineer (PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLS licensed contractor (with hazardous substance certificate) <br /> ❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes, the tank interior atmosphere shelf be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifier's tank management instructions far scrap dealer, disposal facility, etc <br /> A copy of this certificate shall accompany the tank to the recydingldisposal facility, <br />