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TANK CLOSURE CERMFiCA-.1CN FORM <br />On examination of the tanK. I cert 'h IanK i ala (ram product. sludge. scale (thin. laky remdual of tanx =Mani nnsea[e aria aecns. I furffier srdy <br />that the information provides h 1 m:e a ac_ r- o the best of my utowledge. i <br />CERTIFIER SIGNATURE <br />I �irlt ITv 11'FUTlclf G-1C'N <br />_ - I <br />eVsmE55 wuE <br />1 I G. TY d <br />i <br />Ro-Tile <br />CIr Lodi CA 95241-0357 <br />PINE (209)368-6175 <br />DA; c CcRTIFIED sa <br />CERTIFiCATICN TIME <br />310 N. Cluff Ave. <br />auslnEsa _:rY <br />Lodi, CA <br />cs I a`0 pe <br />TANK CvmE0. wuE <br />CI Registered GNxonrnemal Health Soeealist (Rc S) <br />Sm <br />Lavor Thompson <br />L1 Professional Engineer (Pi' <br />AnK CvmEa ♦dCaE>s <br />a0t <br />C Cass It Registered Envirorimental Assessor <br />310 N. Cluff Ave. <br />'AnK.;'M+Ei CITY <br />L1 CSLS licnsad cantracor (with hazardous suostan¢ xmficaliC <br />502STATE 561 <br />I <br />ZIPxN <br />I <br />If yes. the MnK interior atmospnere snail be re.:e:xeo with a adn1pl.5.ble gas <br />Lodi CA <br />CA <br />as2A0 <br />On examination of the tanK. I cert 'h IanK i ala (ram product. sludge. scale (thin. laky remdual of tanx =Mani nnsea[e aria aecns. I furffier srdy <br />that the information provides h 1 m:e a ac_ r- o the best of my utowledge. i <br />CERTIFIER SIGNATURE <br />STATUS CR AFFIUATICN OF CE'-. T IF'ING -SRSCN sos <br />Certifier is a representative of the CUPAIL A: YES Q NO <br />Cc=-1FicR NAME (PRINK Spa R i C I <br />CE71F1ER TITLE sin <br />Contractor <br />Name of CUPA/UA <br />If cerafier's other than CUPP/L:A. creed apFrdcna[e Sax below: <br />� Cerpfied Industrial liessio n (C:H) <br />Q erti�ieo Safety Professional (CSP) <br />AOCRESS P.O. Box 357 <br />CIr Lodi CA 95241-0357 <br />PINE (209)368-6175 <br />DA; c CcRTIFIED sa <br />CERTIFiCATICN TIME <br />Q Carnfied Marine Cnemmt (CMC) <br />CI Registered GNxonrnemal Health Soeealist (Rc S) <br />L1 Professional Engineer (Pi' <br />C Cass It Registered Envirorimental Assessor <br />L1 CSLS licnsad cantracor (with hazardous suostan¢ xmficaliC <br />�t Yes Q No <br />mus tanK predousry nerd lammaole or cnmousodle matenals. <br />If yes. the MnK interior atmospnere snail be re.:e:xeo with a adn1pl.5.ble gas <br />indicator prior to work being conduced on the tank. <br />I Car.ITers tanx management Inca =ons'or scrap dealer, disposal facility, etc: <br />A Cody of this certificate shall acCJmOany the tanK to the feC/Gnglalscosal :acnry. <br />