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TANK CLOSURE CERTIFICATION FORM <br /> TY inFitNTIFIrATION <br /> BUSINESS NAME 1 FACIU Yin. i <br /> Tuff Boy Trailers <br /> SITE ADDRESS IW <br /> 5151 Almondwood <br /> auSINESS CITY Manteca CA +45 aysleg5�;e .� <br /> TANK OWNER NAME 500 <br /> Tuff Boy Leasiniz <br /> TAW OY MER ADDRESS 501 <br /> 5151 Almondwood <br /> 'AW OWNER CITY 542 STATE `AM1 aP S4A <br /> Manteca, CA 95337 <br /> If TANK .1 QSUPF INFQPMA71C)N <br /> Tank st Flammable Vapor Oxygen <br /> (State Tank IRS.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere 1100 gal. unleaded gas <br /> Readings <br /> III r.FRTIFIrATION <br /> On examination of the tank,I certify to i visu duo,sludge.scale(thin,flaky residual at tank contents),rinseate and aeons. I further certify <br /> that the information provided he ' is d actor a to t of my knowledge. <br /> CERTIFIER SIGNATURESTATUS OR AFFILIATION OF CERTIFYING PERSON s4s <br /> CERTIFIER NAME(PRINT) Richard Thor a adifier is a representative of the CUPA/LIA: YES ❑ NO 12 <br /> CERTIFIER TITLE sot <br /> Contractor Name of CUPAILIA <br /> ADCRESS 5151 Almondwood <br /> Manteca,a A If certifter s other than CUPA/LIA check appropriate hoz below: <br /> CIT! M <br /> PHONE (ant c a, CA61 ❑ Certified Industrial Hygienist(CIH) <br /> DATE CERTIFIED CERTIFICATION TIME Q Certified Safety Professional(CSP) <br /> sae <br /> Q Certified Marine Chemist(CMC) <br /> /��/� v //� ✓�j/(�— ❑ Registered Environmental Health Specialist(RENS) <br /> / !_ D y r ,I ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> CSLB licensed contractor(with hazardous substance certificate) <br /> ® Yes ❑ No This tank previously,held flammable or wmbustible materials. If yes.the tank interior atmosphere shall be re-Utecxed with a combustible gas <br /> indicator prior to work being conducted an the tank. <br /> Cartifiefs tank management instructions for scrap dealer.disposal facility,ate: <br /> 2 2 <br /> A copy of this certificate shall accompany the tank to the recyc ing/disoosal facility. <br />