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TANK CLOSURE CERTIFICATION FORM <br /> eU&HESS NAME a' RAGIJTYq• 't <br /> I LA FINCA NUMBER ONE <br /> SmAoonEss 1611 SOUTH AIRPORT WAY ho. <br /> Busimmo m STOCKTON CA 05 ausuEssav 95206 a <br /> TAW(OMER NAME !0a <br /> LA FINCA PARTNERHIP NO . 1 <br /> TAW(o ADWEss <br /> P .O. BOX 1307 <br /> TA O.w+ER CITY GRASS VALLEY SCA SCO 95945 SG <br /> Tank 11 Flammable Vapor Oxygen <br /> (State Tank IDR if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior p-V C>LC;6161D p 0 <br /> Readings <br /> Atmosphere <br /> Raatlin � O � 67 r� <br /> gs rTc <br /> Gv PYA <br /> On examkhaton of the tank.1 certify the tank Is visually free from roducl sludge.scale( in.flaky residual of tank contend) !inseate and debris. I further ce <br /> that the Information provided herein is hue and a tothe b u of my knowledge. O M SFs kT` Xo t Rio <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON soy <br /> CERTIFIER NAME(PRI Z Cardfier is a representative of the CUPAILIAc YES ❑ NO ❑ <br /> CERTIFIER TITLE soT <br /> Name of CUPAILN <br /> ADDRESS '�jDyj 3 If certifier Is other than CUPAILIA checl,appropriate box below: <br /> CITY L Z ❑ Certified Industrial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sos CERTIFICATION TIME ❑ Certified Safety ChemistProfessi (Cnid(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ArN ❑ Professional Engineer(PE) <br /> I13f <br /> 15T '!�""' ., .❑J Class a Registered Environmental Assessor <br /> - CSLB acansed wntractor(with hazardous substance certificate) <br /> as ❑No This tank previously told flammable or combusobte materials. If yes.the tank Interior atmosphere shag be M-checked with a combustible gas <br /> Indicator prior N work being conducted an the tank <br /> Caniflaes tank management Instructions for=211 dealer.disposal facirdy.%to: - <br /> �r Pri l'<}cH V9 <A-#11L S f DSr T1 CW', �rc�G kaVu� <br /> A copy of this ceniflo,te sham accompany the tank to the recyciing/disposal facility. <br />