Laserfiche WebLink
TANK CLOSURE CERTIFICA T ICN FORM <br />Tank i Flammable Vapor <br />(State Tank ]CO. if applicable) Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />Bottom <br />On examination of the lank. I certi tank i at from product. sludge. scale (thin. laky residual of tank contents), rinseate and debris. I further candy <br />that the ❑formation prowtletl h true d ac ra o the best of my knowledge. <br />,�-r r �c wt soy <br />:ERTIFIER NAME (PRINT) spe R,iC <br />3 <br />GAC.IJTY �b <br />Wall ess NAMe <br />.ITY Lodi CA 95241-0357 <br />'HONE (209)368-6175 <br />JA.TE CERTIFIED sos <br />CERTIFICATION TIME <br />Ro-Tile <br />d <br />certified Menne Chemet {CMCJ <br />-Z /' <br />SirE :GCRE55 <br />❑ Registered 'crtvironmental Health Specalist (RE -4S) <br />/ <br />310 N. Cluff Ave. <br />❑ Professional Engineer (PE) <br />r�E�s <br />105 aug",f0 <br />aUSINEaS d�TY <br />Lodi, CA <br />p. CSLB licensed contractor (with hazardous substance certificate) <br />SOD <br />TANK dwNFj: NAME <br />Lavor Thompson <br />TANK :/MER ADpRESS <br />310 N. Cluff Ave. <br />sm STATE Sol DR 5lM <br />TANG vwNER CITY <br />I <br />Lodi CA <br />Tank i Flammable Vapor <br />(State Tank ]CO. if applicable) Top Center Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />Bottom <br />On examination of the lank. I certi tank i at from product. sludge. scale (thin. laky residual of tank contents), rinseate and debris. I further candy <br />that the ❑formation prowtletl h true d ac ra o the best of my knowledge. <br />,�-r r �c wt soy <br />:ERTIFIER NAME (PRINT) spe R,iC <br />Certifier is a representative of the CUPAILIA: YES Q NO Q <br />Name of CUPA/LL4 <br />If certifier !s other than CUPA/UA ciecx appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />:ERTIFIER TITLE 5oT <br />Contractor <br />\DCRESS P.O. BOX 357 <br />.ITY Lodi CA 95241-0357 <br />'HONE (209)368-6175 <br />JA.TE CERTIFIED sos <br />CERTIFICATION TIME <br />certified Menne Chemet {CMCJ <br />-Z /' <br />❑ Registered 'crtvironmental Health Specalist (RE -4S) <br />/ <br />❑ Professional Engineer (PE) <br />❑�(/ Cass II Registered Environmental Assessor <br />p. CSLB licensed contractor (with hazardous substance certificate) <br />® Yes ElNo This tank prewousy held flammable or combustible materials. <br />If yes. the Lank interior atmosphere stall be re -chewed with a bombusnble gas <br />indicator prior to work being conduced on the tank. <br />management Instructions for scrap dealer. disposal %clity. etc0 <br />x <br />DEC 21 1998 <br />I A copy of this certificate shall acoomoany the tank to the recyamg/msposal -aalmy. <br />