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.. y <br /> TANK CLOSURE CERTIFICATICN FCRM <br /> 1 <br /> M. y <br /> I cs I r;y r c. � ctr n a I a.cutvio. , <br /> 'Tony EJockovich Trust <br /> �U <br /> UM ACCRSSS <br /> 767 N. Alpine Rd. <br /> ma aus:�E�215 10° <br /> M' 3blton, CA <br /> TANK CNREIt.` r � <br /> Tony Jockovich Trust pt <br /> TMK cvA ER ACCRES'a <br /> 8569-6rford—Rte-- -- -- --- <br /> TANK CNME4 C1Y Sar TA i C � I L.7 � <br /> Stockton, CA 95215 <br /> I trr+ ncll cl i <br /> TanX x Fammacle vaoor OXYSen <br /> (State Tank!C3.if accii=le) Too Center Satan Tap Canter aattdm <br /> Tank Interior I I/. 6O I I I O <br /> AMCS;tete <br /> Readings <br /> On examination of the tank.I certity the tank is visually free from producL sludge.sale(thin,flaky residual of tank=,tents).dro Bate and dears. I further=rtfy <br /> that Ne information provided herein is true and accurate to the best of my knawledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATiCN CF CERTIFYING PERSON ses <br /> CERTIFIER NAME(PRINT) sce arti i.n or Certifier is a representative of the CUPA/LIA; YES Q NO C <br /> CERTIFIER TITLE sari Name of CJPAJLIA <br /> ACCRESS ox 157 If certifier is adter titan CJPAIUA CteCc aPPMOate bo:belay: <br /> CT( ❑ Cardfied Industhal hygienist(Cltl) <br /> PHCNE — Q CaniSed Safety prcfessianal(CSP) <br /> CATe CERTIFIED sm CERT7FiC.aT10N TIME ❑ Canfied Marne Chemist(CMC) <br /> 6 z 3 ' �33 ,-10 ❑ Registered Environmental HealM SpeCaitst(FE 5) <br /> Q Professicnid Engineer(PM <br /> Q Crass II Registered F-M,,,mo al Assesscr <br /> �1 CSLS licensed=,,,=r(with hazardous substance Cerdfiate)ble as <br /> This tank previausty held flammable or=mbusdble materials. If yes,the IartX interior Ummcnere shall be re-CteCted w M a amen g <br /> Yes ❑No indicator prior to wont being conducted on the tank <br /> CaMfiers tank management irtstrUct! -or scop dealer.disposal faelbty,etc <br /> A=cy at this=fnfiate shall acaambany bte tank to die recfCingldisoasal(aclity �� <br />