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• TANK CLOSURE CERTIFICATION FORM <br /> a.p s <br /> F <br /> au N=w.ua a' c.cwntb. , <br /> Rosenthal Building - TRust <br /> SM! +ooaass 'o` <br /> 24 South American Street <br /> ausr+ess er>' +m wsv,rss yp ,q <br /> Stockton CA 95204 <br /> -..�.epa+ea r..re <br /> sob <br /> Rosenthal Trust <br /> :.aM owwt¢a�doaess 5O1 <br /> c/o Bank of Stockton po box 1110 Stockton CA 95201 <br /> '/aut TwP CTY too STEM !dl Lp '+a <br /> Stockton CA 95201 <br /> 11 TANK Q OctlRE INEOEMADON <br /> Tank a Flammable Vapor Oxygen <br /> (Slate Tank ICS.if applicable) Too Center Sonom Top Canter Bottom <br /> Atmospherer <br /> Readings <br /> I I I <br /> i <br /> I t <br /> On examination of me tank.I cenity,the tank is visually tree from produG stuoge,scale(thin,flaky residual of tank comems),nnseate ane peons. I humor certify <br /> that the informationprovwed h r in' and a ante to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON sm <br /> CERTIFIER NAME(PRINT) toe williamilittle CartiMer is a representative of the CUPAUA: YES ❑ NO ❑ <br /> CERTIFIER TRLE soT <br /> geologist Name of CUPAIL!A <br /> ADORESS <br /> If rarldiw-S other man CUPA/LIA cne k appropriate box below: <br /> CITY Stockton CA 95215 ❑ Certified Industrial Hygienist(CIM <br /> PHONE 209=467-1006 <br /> DA c CERTIFIED too CERTIFICA <br /> 77— TION T IME El �2''e'd Safety Professional(CSP) <br /> ❑ Cerefied Mamie Chemo)(CMC) <br /> ❑ Registered Environmental Health SPe=L-1(RETS) <br /> (/[ r ❑ Professional Engineer(PE) <br /> ss II Registered Environmental Assessor <br /> CSL S licensed contract"(with rumrdous substance cerddmle) <br /> ❑Yes ❑ No This=k preousty t1Nd flammable or combustible materials. If yes.me tank!me=almospnere shad be m-CterXeE"'tm a combustible gas <br /> w <br /> indioter prior to work being conducted on the tank. <br /> Cartifier's tank man igemetm insiruamons for leap dealer.disposal famlity,etc <br /> A copy of this certificate shad accompany me tank 10 LIS recyCing/disposal f"Cif ty. <br />