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TANK CLOSURE CERTIFICATION FORM <br /> xur. a <br /> sUa1..E5a Harp 3 /+wr ul• , <br /> CHEVRON SERVICE STATION <br /> pte•=Ass <br /> 139 S. CENTER STREET, STOCKTON, CR <br /> wsu.Essctr .m auswE55 av .m <br /> rAN.C.V N E sce <br /> CHEVRON PRODUCTS CO. <br /> *+...c+ "x opnpzs so. <br /> 6001 BOLLINGER CANYON ROAD <br /> r+n.�m.En Gr fa3 n+TE fm m SU <br /> SRN RRNON, CR 94583 <br /> 11 TANX -1-0-SURF INE <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank 100,it applicable) Top Center Bottom Top Center Bonam <br /> I Tank Interior <br /> Atmosphere <br /> Readings <br /> III CFRTIFICATIC)N <br /> On examination of the tank.1 Wray the tank d viwaay,tee from product.sludge.scale(thin,flaky residual of tank contents),rinseate and aeons. I trainer mnity <br /> that the information prowded herein a true and acnlrate to the beat of my knowledge. j <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON :=s i <br /> CERTIFIER NAME(PRINT) sps Canine m a representative of the Cl1PAAJA: YES ❑ NO ❑ <br /> CERTIFIER TITLE ser <br /> Name of CUPA/LIA <br /> ADDRESS <br /> CIN It rerdder m w: <br /> other than CUPAn-iA thea[appropriate box below <br /> PHONE ❑ Cerdped IrMwtrial Hyyierim(CIH) <br /> DATE CERTIFIED sea CERTIFICATION TIME ❑ Certipe t Safety Professional(CSP) <br /> ❑ Carolled Manne Chemrat(CMC) <br /> ❑ Registered Emiromnor l Health Spemalist(RENS) <br /> ❑ Prolessional Engineer(PE) <br /> . ❑ Class II Registered Emrironmenral Assessor <br /> ❑ CSLB licensed mrmvaor(with huardow wbstane certificate) <br /> 13Yes C2No The tank previouay,held flammable or combustible materials. It yes.the tam flank interior atmospheshall be re-checked with a epmbwtibb ysa <br /> indicator prior on work being conducted!on the lank. <br /> Cartiflers tank management instructions for scrap dealer,disposal facility,et= <br /> I <br /> A copy or Mix certificate shah accompany Me tank to the recyCbsgldispoaat facility. <br />