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r rcLM <br />T.1NK CLOSURE Ce:MFICATION ECRM <br />P. 13 <br />Tank s <br />(State Tank CO. if apoficaofe) <br />nk Interior <br />nosonere <br />rading. <br />Too <br />Flammable vapor <br />Top j Center ` sadom <br />1 axamtnaticn of the tank. I certify Me tank is visuatty free halm product. sludge. scale (thin, flaky residual of tank Conten s), rfnseate and aeons. 1 further Certify <br />x the information provided herein is true and accurate to the oast of my knowledge. <br />C f C 1 <br />:{MESS "AMC <br />IRTIFiE? NAME (PRINT) sas <br />1 <br />I ?,c:ury.o � 1 <br />+OORSIS <br />'CRESS Q <br />IOA <br />O <br />10fG <br />2 �. <br />;INBSS ttY Q \ ^r <br />103 3l ${NABS CA / 106 <br />,K CAmER ,wMEXM <br />y { <br />�.. �� <br />L yv-i�R. Dor' S�'1 L• L-- G <br />Cl Registered Environmental Health Soeealist (RAS) <br />Q Professional Engineer (PS-) <br />-•K -rNM#.R ::;Y <br />WL <br />J �...� <br />i, A//i a MZP S c/� jQA <br />I 41I J 3 <br />Tank s <br />(State Tank CO. if apoficaofe) <br />nk Interior <br />nosonere <br />rading. <br />Too <br />Flammable vapor <br />Top j Center ` sadom <br />1 axamtnaticn of the tank. I certify Me tank is visuatty free halm product. sludge. scale (thin, flaky residual of tank Conten s), rfnseate and aeons. 1 further Certify <br />x the information provided herein is true and accurate to the oast of my knowledge. <br />;R?IFiER SIGNATURE <br />STATUS OR AF;:ILtATiON OF CERYIFYiNC, PARSON so$ ' <br />Certifier is a napresentative of me CUPA&:A: YES Q NO Q <br />{ <br />IRTIFiE? NAME (PRINT) sas <br />.RTIFIER TITLE sor <br />Name of CUPA,lLIA <br />M eerditer is outer alien CtJPA/L:A Cteck aporopnate aox below: <br />Q Carded Industrial hygienist (CSM) <br />® <br />'CRESS Q <br />CNE p — 3 <br />�T? CERTiFtEO sop <br />C�TIFICATION TIME <br />Cerd�ed Safety PtDf° Q� (CSP) <br />Q CerttBed Marano Chantst (CMC) <br />Cl Registered Environmental Health Soeealist (RAS) <br />Q Professional Engineer (PS-) <br />Q Cass if Registered Eavimnmenutf Assessor <br />• <br />CSLS licensed A1nt scar (Vnth narnMous substance wrtHIC31e) <br />' Yes ❑ No T Tr tank orevicusty heid fiammaole ar combustible matenals. It yes. me tank interior atmesonere shall tae ns-dteCced -41 a combustible 9= <br />indicator prier b work being conducted an the tank. <br />Knfiers tarm management instrucdons for scrap deafer, disoosai facifity. etc <br />A cooy of Rus Certificate sham accomoeny the tank to tie MVycingMisoasal facility. <br />