Storage tank system identification form: part VI

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Part VI: Withdrawal from Service and Removal

Status of Tank and Piping

Complete applicable section only: Permanent withdrawal, removal or temporary withdrawal)

Temporary withdrawal from service ^Footnote4 in accordance with sections 43 of Regulations
(Review Section 43 of the Regulations for details regarding mandatory return to service testing)
Information	Tank 1	Tank 1 Piping	Tank 2	Tank 2 Piping	Tank 3	Tank 3 Piping	Tank 4	Tank 4 Piping	Tank 5	Tank 5 Piping
EC Tank System Identification Number
Start date (MM/YYYY)
End date (MM/YYYY)

**Permanent withdrawal completed in accordance with sections 44 of Regulations**
(Check **all** that apply)
Information	Tank 1	Tank 1 Piping	Tank 2	Tank 2 Piping	Tank 3	Tank 3 Piping	Tank 4	Tank 4 Piping	Tank 5	Tank 5 Piping
Date permanently withdrawn from service (MM/YYYY)
Withdrawn by approved person	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Withdrawal records kept	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Liquids/sludge removed and disposed	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Vapours purged	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
No long-term harmful effects^Footnote5	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Fill pipe labelled	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Physically removed	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No

**Removal completed in accordance with section 45 of Regulations**
(Check **all** that apply)
Information	Tank 1	Tank 1 Piping	Tank 2	Tank 2 Piping	Tank 3	Tank 3 Piping	Tank 4	Tank 4 Piping	Tank 5	Tank 5 Piping
Date removed (MM/YYYY)
Removed by approved person	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
Removal records kept	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No	◻ Yes ◻ No
* Certified person’s certification number

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2017-01-23