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TANK CLOSURE CERTIFICATION FORM <br /> � s <br /> F <br /> BVsiwESswuE � c�CUTYw• , <br /> Rosenthal Building - TRust <br /> STE -ESS '« <br /> 24 South American Street <br /> eVsiNESS CITY ,p5 wSiwEtS]v roe <br /> Stockton CA 95204 <br /> TANK CV E 500 <br /> Rosenthal Trust <br /> .1 K c"IEA r.odKESS a0, <br /> c/o Bank of Stockton po box 1110 Stockton CA 95201 <br /> TAW�"CTY 5(a sTwTE SC] u'P Sal <br /> Stockton CA 95201 <br /> 11 TANK 01 (RE INEORMAEON <br /> Tanks Flammable Vapor Oxygen <br /> (Slate Tank ICS.if applicab e) Too Center Banom Top Cerner Bottom <br /> T ank Interior <br /> Atmosphere <br /> Readings <br /> On examination of the tank.I cenity the tank is Visually free from product.sludge,scale(Nin,flaky residual of tank comems).rinsewe and neons. 1 further ceniy <br /> that the mfonnallon provided herein is true and accurate to the 'best of my kno ledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSCN sas <br /> CERTIFIER NAME(PRINT) sm Carnfier is a representative of the CUPAUA: YES ❑ NO ❑ <br /> CERTIFIER TLTLE sot <br /> geologist Name of CJFAM <br /> ADDRESS 837 -haw rnnd <br /> If certifier is other than CUPA/L'Js C,ecX appropriate Da:below: <br /> CITY stockton CA 95215 <br /> ❑ Certified Industrial Hygienist lGM <br /> PHONE 209=467-1006 <br /> DATE CERTIFIED sn CERTIFICATION TIME F1Certteo Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Eriwonmental Health Specialist(RE-'S) <br /> ❑ Professional Engineer(PE) <br /> :ass II Registered Erwironmental Assessor <br /> CSL S licensed contractor(with hazardous substance certificate) <br /> 13 Yes ❑ No This tank previousy held flammable or combustible materials. It yes.the tank interior atmosphere shall be we eeced wdh a Combusobie gas <br /> indicator prior to work being conduced on the tank <br /> Canifiefs UnK management instructions for scrap deaw,disposal tacitly.etc <br /> A copy of this certificate shall accompany the tank 10 the mcYci g/disposal facility. <br />