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TANK CLOSURE CERTIFICATION FORM <br /> � a <br /> 3 FACIUW ID <br /> 9USINE55 NAME 4027 <br /> A. Teichert & Son. Inc. D <br /> SITE ADDRESS <br /> 103 North E Street <br /> X05 aUSINESS Lo t00 <br /> BUSINESS Cnv <br /> Stockton Soo <br /> TANK OWNER NAME <br /> A. Teichert & Son Inc . m, <br /> tANKk ER ADDRESS <br /> P.O. Box 15002 <br /> 5@ STATE 303 av sa <br /> TANK DYMEfl CIN <br /> Sacramento CA 95851 <br /> Tank# 11 TANK Flammable Vapor Oxygen <br /> (Slate Tank DO.if applicable) Top Center Bottom Tap Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III rFRTlFirATl0N <br /> On examination of the tank.I certify the tank is visually free tam product,sludge.scale(thin,flaky residual of tank contents),create and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON cos <br /> CERTIFIER NAME(PRINT) ske Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sor Name of CUPA/LIA <br /> ADDRESS If certifier is other than CUPA/LIA check appropriate box below: <br /> CITY ❑ Certified tndusbial Hygienist(CIH) <br /> PHONE <br /> DATE CERTIFIED sos CERTIFICATION TIME C3 Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSI.B licensed contractor(with hazardous substance certificate) <br /> This tank previously held flammable or combustible materials. It yes.the tank interim atmosphere shall be re-checked with a combustible gas <br /> ❑Yes ❑ No <br /> indicator prim to work being conducted on the tank. <br /> Certifier's tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this camficate shall accompany the tank to the recycling/disposal facility. <br />