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ti <br /> TANK CLOSURE CERTIFICATION FORM <br /> F� x <br /> BUSINESS NAME 3 FACIUTV Ip• <br /> Central California Traction Co. <br /> SITE AdaRESS <br /> 1645 Cherokee Rd. <br /> SKEINESS CITY Stockton, CA 'ss los <br /> TANK ONMER NAME SW <br /> Central California Traction Co. <br /> TANK GAMER ADDRESS JCt <br /> 1645 Cherokee Rd. <br /> TANK OWNER CITY SdZ STATE 503 r3P Sar <br /> Stockton, CA 95205 <br /> Tank N Flammable Vapor Oxygen <br /> (State Tank ION.if applicable) Top Center Bottom Top Center Bottom <br /> Tank tnlenor <br /> Atmosphere <br /> Readings <br /> coo C- 0iQ <br /> III rFRTIFIrATION <br /> On examination of the tank,I cert) ank is v' m product.sludge.scale(Nin,flaky residual of tank contents),rinseate and deans. I further Ccertdy <br /> that me information provided h i e an acw t the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIAnCN OF CERTIFYING PERSON 1�t sos <br /> CERTIFIER NAME(PRINT) Solt 1C ar or Certifier is a representative of the CUPAILIA: YES F2NO 14 <br /> CERTIFIER TITLE stir <br /> Name of CUPA/LIA <br /> AODRESS If certifier is other than CUPAILIA check appropriate box below: <br /> CITY <br /> PHONE ❑ Certified IntluStnal Hygienist(CIH) <br /> DATE CERTIFI D sol CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> �/�/�� ❑ Certified Marine Chemist(CMC) <br /> f �` ❑ Registered Environmental Health Specialist(REriS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> CSLS licensed contractor(with hazardous substance certMrate) <br /> Yes ElNo This tank previously held flammable or combustible materials. If yes,the tank interior atmosphere Shall be re-=ecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiefs tank management instructions for scrap dealer.disposal facility,etc: - <br /> A copy of this certificate shall accompany the tank to the recycong/disposal faaiity. <br />