Laserfiche WebLink
TANK CLOSURE CERTIFICA-11CN FORM <br />I C. <br />Ro-Tile <br />310 N. Cluff Ave. <br />Lodi, CA <br />Lavor Thompson <br />310 N. Cluff Ave. <br />Lodi CA <br />I rA <br />nr nC' ipc I RnG 1 <br />TanK 2 <br />Pammacle `/aoor CxySen <br />Bottom Top I Cznter <br />3attom <br />�State Tanx ICS d aocilaoie) <br />Too Canter <br />TanK mtenor <br />Atmoscnere <br />Readings <br />,-5 <br />Ll <br />r p- ct Tt <br />On examination of the tanK. I cert1 tanK i - a1 4 from product. sludge. sale <br />(Nin. 9aKY residual of tanK contentU hnseate and aeons. I further xndy <br />t11a[ me informationp;oaded h i due o ac_ ra o Me best of my :<noWredge. <br />SCS <br />IL:ATICN OF CF'ING PERSON <br />STATUS CR AFPEHTI <br />T <br />CER -1 SIGNATURE <br />Cartifier is a representative of the CUPAILA: YES Q NO <br />Name of CUPA/L'A <br />if certifier is other than CUPAIL:A thecae approcnate oox belcw: <br />Gt Certified!ridustnal Hygienist (C:H) <br />Q Certifies Safety Prdfessianal (CSP) <br />❑ Chemist fV-IC) <br />CER T IFiE.R NAME (PRINK sod R 1C <br />CERTIFIER TITLE sm <br />Contractor <br />ACCRESS P.O. BOx 357 <br />CIT' Lodi, CA 95241-0357 <br />PHONE (209)368-6175 <br />DA.- CERTIFIED sad <br />CERTIFICATION TIME <br />ZI <br />,�w.� <br />Certified Mame <br />Registered Ewronmentai Health Soecalist (R� Si <br />/J' <br />❑ Professional Engineer (PSI <br />Cass 11 Registerea Environmental Assessor <br />CSIcS licensed contractor (With hso:smous Sudstanoe cera(atel <br />This .anx previouSly heid'lammadie or conioustibie maten2m. it yes. the tanK intenor aanospilCre Shall be 'ecud With a =mduSi:hie gas <br />® Yes ❑ <br />No <br />Ino rator prior to Wer% being conducted an the tanK. <br />Certifiers tanK management inswucdotls for scrap assist. disposal faclity. etc: <br />