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TANK CLOSURE CERTIFICATION FORM <br /> e mNEss NAVE The City Of Stockton RDiy s PAuuTY io. <br /> SITE♦OGRESS - �« <br /> 310 S. American St . <br /> suslNEss CITY Stockton, CA <br /> TANK OWNER NAME w ` SCO <br /> The City of Stockton <br /> TANK OWNER ADDRESS <br /> 305 N. E1 Dorado St <br /> TANK OWNER CITU 502 STATE 'A] ➢P SO• <br /> Stockton, CA 95202 <br /> Tank# Flammable vapor Oxygen <br /> (State Tank IDs,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rF=RTfFIrAT1QN <br /> On examination of the tank.I certify the tank is visually free from product.sludge,scale(thin.flaky residual of tank coments).rinseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE rSTATUS AFFILIATION OF CERTIFYING PERSONrtCERTIFIER NAME(PRINT) solilartin Thor arepresentative of the CUPAILIA: YES ❑ NO "XCERTIFIER TITLE wT ContractorAILIA <br /> ADDRESS oNer than CUPAfI.IA cttecx appropriate box beklw: <br /> CITYd Industrial Hygienist(CIH) <br /> PHONE — <br /> OATE CERTIFIED roe CERTIFICATION TIME d Satary Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> jo CSLB licensed contractor(with hazardous substance cefbfldate) <br /> 'CJ Yes [2No This tank previously held flammable or combustible materials. It yes.the tank interior atmosphere shall be re-checKed with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Camfiefs tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recycling disposal facility. <br />