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TANK CLOSURE CERTIFICATION FORM <br /> F I <br /> BUSINESS NA•IAC- C 3 :AGIJTY �D • <br /> SITE +DCNESS <br /> 2 Sc � eeT Si oCKTon A `i5Zo5 <br /> 3USINESS CITY lee duSINESS :,P •�z L3 :OD <br /> - JJ <br /> TANK CwNER NAME 500 <br /> Fill AeS "_ EZoDi IN4 <br /> TANK CVVWER ADDRESS 'ar <br /> 'ANK CvmER CITY SP! STATE 'AT IIv SM <br /> S o io C� g52r, <br /> 11 TANK Q QSf IEF INFORMATIQU <br /> Tank Y' Rammaole Vapor Oxygen <br /> (Slate Tank ICS, if applicable) Tod Center Bottom Top Canter Sonom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> 111 CPR71F;rATtQN <br /> On examination of the tank. I certify the tank is visually free from product sludge. smle (thin. flaky residual of tank contents), rinseate and aeons. I further wraty <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATICN OF CERTIFYING PERSON sas <br /> CERTIFIER NAME (PRINT) sae Certifier is a representative of the CUPA/LIA: YES Q NO ❑ <br /> CERTIFIER TITLE stir <br /> Name of CUPP/LIA <br /> ADORESS If certifier is other than CUPAlUA check appropriate box below: <br /> CITY <br /> ❑ Certified Industrial Hygienist (CIH) <br /> PHONE <br /> C3 Certified Sarin Professional (CSP) <br /> DATE CERTIFIED 5011 CERTIFICATION TIME <br /> C1 Certified Marine Chemist (CMC) <br /> ❑ Registered Environmental Health Specialist (RE: 4S) <br /> ❑ Professional Engineer (PE) <br /> Q Crass II Registered Environmental Assessor <br /> ❑ CSLS licensed mnllHcor (with hazardous Substance certifimte) <br /> ❑ Yes ❑ No This tank previously held flammable or combustible materials- If yes, the tank interior atmosphere shall be re-checked with a mmbusbtile gas <br /> indimtor prior to work being conduced on the tank. <br /> Camfiers tank management instructions for scrap dealer, disposal fadlity, etc <br /> A copy of this srtifimte shall accompany the tank to the recyc:mg1disposal faality. <br />