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TANK CLOSURE CERTIFICATION FORM <br /> C 1 <br /> 3USIwESS MANE � FAg1IJTV W• � <br /> A. Teichert & Son, Inc. 4027 <br /> r� aODnE55 Iy <br /> 103 North E Street <br /> 3v5:.ESS Clio Stockton 952n5 105 3USINESS Dv Im i <br /> -ar+x CwnEa iwlrE Soo <br /> A. Teichert & Son Inc . j <br /> ar+[=.ER♦00ACSS 50t <br /> P.O. Box 15002 <br /> 'a.x C:vr/ER Civ 502 iTATE 50] ]v SOa <br /> Sacramento ICA 195851 <br /> It TANK Q! <br /> Tank S r ammaole Vapor Oxygen <br /> (State Tank IC*,if applicable) Top Canter Bottom Top Canter Bonom <br /> "anxlntenor <br /> apngs fe <br /> R 1555-5 28 I 3% <br /> 1555-6 128 I 68 <br /> I <br /> I <br /> 1555-8 12% 6% <br /> III r I <br /> :n exammanon of the tank. I cemty,he tank is wsuady free from product.sludge.scale(thm,laky residual of tank WhiteMs).roseate and aeons. I huther carufy <br /> 'hat he information proneed herein Is true and accu ite to the best of my knowledge. <br /> RTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSCN Sas <br /> :ERnFIER NAME(PRINT) ice Certifier Is a representative of the CUPAAJA: YES ❑ NO ❑ <br /> ZERTIFIER TITLE wT <br /> Name of CUPA/L1A I <br /> ACCRESS If certifier Is other than CUPAILIA check appropriate box below: <br /> :Ii. <br /> C3-HCNE Carolled Indutri <br /> sal Hygienist(CIM) <br /> DA—,E CERTIFIED soe CERTIFICATION TIME Q Candied Safety Professional(CSP) <br /> Q Cartlfied Marine Cbemisn(CMC) <br /> ❑ Registered Enwonme ital Health Speaafist(REnS) <br /> ❑ Professional Engineer(PE) <br /> Q Cass It Registered Ennronmental Assessor <br /> • ❑ CSLS licensed wnpaaor(with hazardous substance cerofiaate) <br /> ❑ NO This tank prem uslY ned flammable or combustible materials. it yes.the lank interior atmosphere shad be re cheoced with a comoustible gas <br /> "es Indicator on"to work being conducted an the tank <br /> �amfier5 tank management instructions far scrap dealer,disposal facfity.etc <br /> I <br /> I <br /> A Copy of this certificate snail accompany he tank to the reC/Cingldisposal faafity. <br />