Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br />Rsw n <br />F <br />BUSINESS NAME <br />Air Port Way Tjjhp C.'Pntpr <br />1 <br />FAC:IJTY ID • 1 <br />WE aDORESs <br />442 N. Air Port Way <br />tM <br />BISMSS CITY <br />Stockton CA <br />105 <br />1 <br />aUSINESS DR 1011 <br />95205 <br />TANK CNMER NAME <br />Raymond Lopez <br />500 <br />TANK OWNER ADDRESS <br />N. Air Port Way <br />'Qt <br />TANK OWNER CITY442 <br />Stockton, <br />5@ <br />STATE 56] <br />CA <br />PR SW <br />95205 <br />11 TANK r.1 SI IERE <br />INFQRMAj1rN <br />Tank 3 <br />(State Tank 103, if applicable) <br />Rammacle Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />4Jr �tJ <br />III (7.1FRTIFICATInN <br />On examination of the tank, Ice - ank is visual product, sludge. scale (min, flaky residual of tank contents), rinseate and deons. I further certify <br />that the information prowdetl h ei e a ccur o best of my knowledge. <br />CERTIFIER SIGNATURESTAT <br />US OR AFFILIATION OF CERTIFYING PSRSCN eas ' <br />Cartifier is a representative of the CUPA/LIA: YES ❑ NO L3` <br />Name of CUPAILIA <br />If cemfier is other than CUPA/LIA Check appropriate box below: <br />11 Certified Industrial Hygienist (CIH) <br />❑ Candied Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Environmental Health Specialist (RE'—'S) <br />❑ Professional Engineer (PE) <br />r❑r� Class It Registered En-Aronmental Assessor <br />L'3 CSLB licensed contractor (with huardous substance, certfieate) <br />CERTIFIER NAME (PRIN sae ' R <br />CERTIFIER TITLE w7 <br />Contractor <br />ADDRESS P.O. BOX 357 <br />CITY Lodi <br />CA <br />PHONE 209 <br />368-6175 <br />DATE CERTIFIED sos <br />-r// M��j (/ <br />/ G J O/ Q <br />CERTIRCAT10N TIME <br />//,r �',�^ <br />, — t <br />• <br />Yes ❑ No This tank prewousty held flammable or combustible materials. <br />indicator prior to work being conducted on the tank. <br />If yes, the lank interior atmosphere shall be re -checked with a combustible gas <br />Car ifiers tank management instructions for scrap dealer. disposal facility, etc: <br />- <br />A copy of this co ficate shall accompany the tank to the recyCing/discOsal fadiity. <br />