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E <br />TANK CLOSURE CERTIFICATION FORM <br />I CA NI ITV Im ChMICir` ATVYM <br />SUSINESSNAME CAPITOL AUTO SALES <br />r <br />wSClur lo. <br />-I <br />SITE ♦OGRESS <br />IM <br />650 E. MINER AVENUE, STOCKTON, CALIFORNIA 95202 <br />SUSINESS CITY STOCKTON Ips <br />allSINESS LP <br />95202 1% <br />TANK 0YM NAME <br />!CO <br />JAGENDER SINGH <br />TANK OWNER ADORESS <br />SOI <br />650 E. MINER AVENUE <br />TANK OWNER CITY <br />SM <br />STATE 503 <br />nP SM <br />STOCKTON <br />CA <br />95202 <br />Tank a <br />(State Tank IDS, if applicable( <br />Tank interior <br />Atmosphere <br />Readings <br />Top <br />aoctom <br />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 <br />that the information provided herein is true and accurate to the be:A of my knowledge. <br />CERTIFIER SIGNATURE _ <br />CERTIFIER NAME (PRINT) 50e <br />CERTIFIER TITLE so, <br />ADDRESS <br />CITY <br />PHONE <br />DATE CERTIFIED we CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable ar CO;W usbble materials <br />indicator prior to work being conducted on ti•e tank. <br />Certifiers tank management instructions for scrap dealer. disposal facility, etc <br />STATUS OR AFFILIATION OF CERTIFYING PERSON SOS <br />Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br />Name of CUPA/LIA <br />If certifier is other than CUPA/LIA dceck appropnate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional ((SP) <br />❑ Cendled Marine Chemist (CMC) <br />❑ Registered Environmental Heafth Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class It Registered Environmemal Assessor <br />❑ CSLS licensed contractor (wilt, hazardous substance certificate) <br />If yes, the tank interior atmosphere shall be rechecked with a combustible gas <br />I A copy of this arfiflate shall accompany the tank to the recyciing/disposal faciiih . __ <br />