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TANK CLOSURE CERTIFICATION FORM <br /> .1. E:1r.IjrrY1MF:N7WTr.ATI0N <br /> 3 PaC:UTY�d• , <br /> aU51NEsa NAMe The City of Stockton — RDA <br /> sfre aGCREss tW <br /> li 310 S. American St . $$ <br /> Its �t151NE t/ P :Le <br /> still <br /> ETANKa�GR <br /> Stockton, CA yOG <br /> UMA The City of StocktonOCRESa <br /> 305_N. E1 Dorado StITY 503 sTATa 563 37P - SW <br /> Stockton, CA I 95202 <br /> Tank S Flammable vapor Oxygen <br /> (State Tank lc#. :f applifaole) Top Center Bottom Topcanter Sodom <br /> Tank Interior , I O 6 0 0 - 1 " ' 9 I 0 , 7 <br /> Atmospnere <br /> Readings <br /> On examination of the tank.I certify the tank is visually free from product sludge.scale(Nin.flaky residuai of tank contents),nmseate and aeons. I further certify <br /> that the information pmvWed herein is true and accurst the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PcRSCN �7, its <br /> CERTIFIER NAME(PRINT) art in Thorpe Cartifier is a representative of the CUPAIUA: YES 11 NO `A <br /> CERTIFIER TITLE son Contractor Name of CUPA/LIA <br /> AOORESS T) Z If certifier is other than CUPA&A cited(appropriate box below: <br /> CM ❑ Certified industrial Hygienist(CIH) <br /> PHONE _ ❑ Certified Safety Professional(CSP) <br /> DATE CERTIFIED cos CERTIFICATION TIME <br /> ,1U ysy ❑ Certified Monne Chemist(CMC) <br /> 5 't o - Z / I 1/ /y ❑ Registered Environmental Health Specialist(RE'-S) <br /> ❑ Professional Engineer(PE) <br /> ❑ Gass II Registered Emnrammental Assessor <br /> CSLB licensed contractor(with hazardous substance 2rMlcate) <br /> Yes Q No m <br /> This tank previously held flammable or comousbble materials. If yes.the tank interior atmosphere snail be re-checked with a combusable gas <br /> indicator prior to work being conducted an e tank. <br /> Camfiefs tank management instmctions for soap dealer,disposal facility, etc: <br /> A copy of this certificate shall acwmpany the tank to the mcyciing/disposal fac;W <br />