COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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TANK CLOSURE CERTIFICATION FORM I Tank Interior Atmosphere Readings BUSINESS NAME 3 FACIUTY 10 • 1 S'Nw 'Z Center SITE ADDRESS I1O4 5— P,Z s-' c 7f2 wC 2 5 BUSINESS CITY \` 105 ,U auSINESS LP 105 TANK OWNER NAME Soo U TANK OWNER ADDRESS 501 5 M� 0 TANK OWNER CITY 502 STATE 503 IIP 504 c�l. N = c1 V t. I Tank Interior Atmosphere Readings 11 LAW Tank 0 (State Tank 10*, if applicable) 11RENE0 RAA ON Flammable Vapor Oxygen Top Center Bottom Top Center Bottom STATUS OR AFFILIATION OF CERTIFYING PSRSON 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER NAME (PRINT) SOB CERTIFIER TITLE 5w Name of CUPA/L!A thIf certifier is other an CUPA/L1A check appropriate box below: ADDRESS circ ❑ Certified industrial Hygienist (CIH) ® Certified Safety Professional (CSP) PHONE DATE CERTIFIED sos CERTIFICATION TIME ❑ Certified Marine Chemist (CNC) ❑ Registered Environmental Health Specialist (REHS) I ❑ Professional Eng' (PE) III r;=P"nI:IrATI0N On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin, flaky residual of tank contents), rinseate and debris. I further certify that the information provided herein is true and accurate to the best of my knowledge. CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PSRSON 505 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ CERTIFIER NAME (PRINT) SOB CERTIFIER TITLE 5w Name of CUPA/L!A thIf certifier is other an CUPA/L1A check appropriate box below: ADDRESS circ ❑ Certified industrial Hygienist (CIH) ® Certified Safety Professional (CSP) PHONE DATE CERTIFIED sos CERTIFICATION TIME ❑ Certified Marine Chemist (CNC) ❑ Registered Environmental Health Specialist (REHS) ❑ Professional Eng' (PE) ❑ Class If Registered Environmental Assessor ❑ CSLS licensed contractor (with hazardous substance certificate) ❑ Yes ❑ No This tank previously hold flammable or combustible materials. If yes, the tank interior atmosphere shag be re -checked with a combustible gas indicator prior to work being conducted on the tank. Certifier's tank management instructions for scrap dealer, disposal facility, etc A copy of this certificate shall accompany the tank to the recydingidisposal facility.