Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM a <br /> BU6INESS ruME 1 FAGtJTy iD• t <br /> FOWLERrS <br /> sire aooaess <br /> as <br /> 405 N. EDISON STREET <br /> ""'I SscnY STOCKTON, CALIFORNIA }LU�ZIP ,ro <br /> rAak ow>rEa hr Re ROY FOWLER <br /> o, <br /> TNI(0w1,1E0.nppRE59 <br /> 405 N. EDISON STREET <br /> iiot STATE 507 IIP 50� <br /> rutxw.mEaaTrSTOCKTON CA 95203 <br /> Tank a Flammable Vapor. Oxygen <br /> (Slate Tank IDa.if applicable) Top Center Bottom Top I Career Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> fit r.FRnF1rAT1QN <br /> On examination of the tank.I calmly the tank is visually free from produci.sludge.scale(thin.flaky residual of tank contemsl,imseate and oebns. I further certify <br /> that the information provided herein is true and acci to the best of rm knowledge. <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> CERTIFIER SIGNATURE sos <br /> CERTIFIER NAME(PRINT) sae Certifier is a representative of the CUPAILIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE eoT Name of CUPAILIA <br /> ADDRESS If cenffer is other than CUPAILIA check appropriate box below: <br /> CITY ❑ Candied Indminal Hygienriat(CIH) <br /> PHONE <br /> D ❑ Certified Safety Professional(CSP) <br /> ATE CERTIFIED sae CERTIFICATION TIME <br /> ❑ Carolled Marne Chemet(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> ❑ CSLS licensed contractor(with hnarcous ebbStan2 certificate) <br /> ❑Yes 12 No This tank premousy held flammable or comtlustible materials. 11 yes.the tank interim atn'twohem shad be rechecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Camfiers tank management instructions for scrap dealer.disposal facility,etc: <br /> I <br /> I <br /> A copy of this cemfitate shall accompany the tank to the recyCing/disoosal facifity. I <br />