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TANK CLOSURE CERTIFICATION FORM <br />G <br />BUSINESS NAVE <br />s .Ac:urvioa + <br />Redevelopment A enc of Stockton <br />SITE ,CCRESS; <br />o. <br />Block Bounded by Lafayette, E1 Dorado, Center and Sonora Streets <br />ausiNess clT Stockton <br />+os <br />auswessav 95202 'aa <br />TANK VW W 14ME <br />tN <br />Redevelopment AGency of Stockton <br />TANG C. IIA ADDRESS <br />al+ <br />305 N. E1 Dorado Street, Suite 200 <br />'ANN CNNER CITY5@ <br />STEM 103 <br />7R tM <br />195202 <br />Stockton <br />CA <br />Tank a <br />Flammable Vapor Oxygen <br />1 <br />(State Tank ICS. if applicable) <br />Top <br />Cen[er Bottorn Top <br />Canter <br />Bottom <br />Tank mtenor <br />Atmosphere1,000 <br />tank <br />0 <br />0 <br />0 <br />20.8 <br />20.8 <br />Raaaing3ings <br />g al <br />III rFRTIFIr.ATIQN <br />On examination of the tank, I certify the tank IS visually free from proauct. sludge. sole (thin. lazy resioual of tank comems), rinseate and aeons. I hather oerttfy <br />that the information provided hemin is true and aaarate to the oast of my knowledge. <br />CERTIFIER SIGNATURE <br />! STATUS OR AFFILIATION OF CERTIFYING PERSON IDS <br />Cartifier is a representative of the CUPARJA: YES ❑ NO ❑ <br />CERTIFIER NAME (PRI John raw or <br />CERTIFIER TITLE W7 <br />Project Manager, EBI <br />Name of CUPAILIA <br />If cartifier b other than CUPAILIA Check approonate box below: <br />ADDRESS J589 Nationalrive <br />CITY Livermore, CA <br />❑ Caroled Ithoraaial Hygienist (CbH) <br />❑ Cartified Safaty Pro(esalenal (CSP) <br />PHONE 925-443-0225 <br />DATE CERTIFIED sos <br />CERTIFICATION TIME <br />12 Aug 99 <br />1430 Hrs. <br />❑ Certified Mamu Chemrst(CMC) <br />❑ Registered Emmonmamal Health Specialist (RENS) <br />❑ Professional Enlimastr(PE) <br />❑ Calls II Registered Eavironmencal Assessor <br />• <br />Ja CSLB Ikensed contractor (with habudous substance cartlflatel <br />❑ Yes ❑ No This tank previously held aemmable a comousbble materials. <br />if yes. the tank interior abnasphem stall be with a combustible gas <br />indicator prior to warn, being conducted an the tank. <br />Camfiers tank management instructions for scrap dealer, disposal facility, etc <br />_ <br />Tank scrap metal is free of residuals and shows <br />no flammable vapors. <br />A dopy of this amfiate shall accompany its tank to the recycingldlsuosal faciifry. <br />