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TANK CLOSURE CERTIFICATION FORM <br />. <br />BUSINESS NAME S' <br />FACILTY rd s ' <br />SITE AOORESS <br />tOa <br />BUSINESS CITY au5wE5S bP <br />- <br />TANK OWNER NAME 500 <br />EF�N S 2 /S 1-"C '& O L <br />TANK OWNER AOORESS 501 <br />Jab C. -1Zo7--,q ,c <br />TANK OWNER CITY 502 <br />STATE SOS <br />IIP Spa <br />I/- " "7`/`f r< 6 P <br />I <br />4f /f <br />1 9s yG <br />Tank $ Flammable Vapor Oxygen <br />(State Tank IDsf, if applicable) Top Center Bottom Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />1 <br />III (.F-RTIFI!CATIQN <br />On examination of the tank. 1 certify the tank is visually free from product, sludge, scale (thin. flaky residual of tank contents), rinseate and debris. 1 furrier certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON Sas <br />Certifier is a representative of the CUPA/UA: YES ❑ NO Q <br />Name of CUPA/UA <br />If certifier is other than CUPAIL A check appropriate box below: <br />_ <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) _ <br />❑ Registered Environmental Health Specialist (R&iS) <br />❑ Professional Engineer (PE) <br />❑ Class 11 Registered Environmental Assessor <br />Q CSLS licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) soe <br />CERTIFIER TITLE 507 <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED sa8 <br />CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. If yes, the tank interior atmosphere shalt be re -checked with a combustible gas <br />indicator prior to work being conducted on the tank. <br />Cartifier's tank management instructions for scrap dealer, disposal facility, etc: <br />A copy of this certificate shall accompany the tank to the recyc ing/disposal facility, <br />