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... <br />TANK CLOSURE CERTIFICATION FORM <br />R4 M <br />A copy at this cartmcete snail accompany me tanN w me <br />94JSINESS NAME <br />A. Teichert & Son, Inc. <br />1 <br />FACAUTV IO• ' <br />1555 <br />Sm=. AooREss <br />103 North E Street <br />'a' <br />auslNEae Clry Stockton <br />Its <br />P tae <br />9520 <br />39MrO 54 <br />TANK OWNER NAME <br />A. Teichert & Son, Inc. <br />SW <br />TANK OMER AOORESS <br />P.O. Box 15002 <br />So' <br />TANK OWNER CITY <br />Sacramento <br />Sat <br />STATE Sea <br />CA <br />DP SIH <br />95851 <br />Tank x <br />(State Tank 100, if applicable) <br />Flammable Vapor Oxygen <br />Tap Center Bottom Top <br />Center <br />Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />ill rFRTIFirATION <br />On examination of the tank. I certify the tank is visually free from product. sludge. scale (thin• flaky residual of tank contents). nnaeate and aeons. I further certify <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON roe <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br />Name of CUPA/L1A <br />certifier is other than CUPA/LIA Check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />Professional (CSP) <br />13 Certified Safety Chemist <br />Certified Mee Chemistt ( (CMC) <br />❑Caronth <br />❑ Registered Environmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑ Class if Registered Environmental Assessor <br />❑ CSLB licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) sea John SaVidge <br />CERTIFIER TITLE ter <br />Owner <br />ADDRESS 4401 SOn •a Court.If <br />CITY Placerville <br />PHONE C530622-1982 <br />DATE CERTIFIED sae <br />CERTIFICATION TIME <br />❑ Yes ❑ No This tank previously held flammable or combustible materials. <br />indicator prior to work being Conducted on the tank. <br />If yes. the tank interior atmosphere shall be re -checked w@h a combustible gas <br />Cartifier•s tank management Instructions for scrap dealer, disposal facility, etc: <br />A copy at this cartmcete snail accompany me tanN w me <br />