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12/03!2003 13:10 2094671119 AGE STOCKTON PAGE 07/09 <br />TANK CLOSURE CERTIFICATION FORM <br />r <br />eY9WS6 RArg <br />VW l'V_ <br />a <br />FAaurvlDe r <br />SnE ArafRda� <br />ro <br />CSS <br />a<nwssarY CLC, <br />tae a � <br />' TArMCerrgRAua <br />1 <br />1V <br />.. <br />rAwR cr«aa ADOMEaa <br />»f <br />rAwtcnautan <br />in <br />sTAr sa <br />fe.. <br />ySB3 <br />Tankx <br />(State Tank ICs, If appaohle) <br />Flammable vapor amen <br />Top <br />Center BdLWm To5ie <br />Tank Interkr <br />_ <br />Air phen ` \ <br />O <br />�.• rriis <br />It rERnFlr-ATinN <br />On the inf ebdn of the renk.ide I ramify tie tank h atsfalac hes horn pr lftm- SI(Idge, =10 (thin, Aaky residya( of I=K CaneMRl• dnaeea, and da" I Atha oardN <br />that the natianSiGNA Orovldea tbnLf is flue and atCware to <br />Ifle hest of u7 knGwledgs <br />IIEA <br />CERTIFIER SIGNATURE <br />CERTIFIER NAME (PRIME) <br />STATU8 QR AFFlLU'RON OF CERTIFYING PeR$ON fq <br />C27Tlp1 ER TITLE ser <br />Certlpbr is a reptbserlt*f A df the CUPAAJA: YES ClNo ❑ <br />A0QRei= <br />Narne of C(JPARJA <br />G7TY <br />If dortMa a other Men CLIPAn.U1 coed% a,O,dMt*p boa bekfw; <br />PHONE <br />Q CdMed lndPsoisl Hygienist (Cltq <br />DATE CER'TIFI£C ora CERTIFICATION TIME <br />0 Certified Safety pmfesSipry (CSp) <br />CarrteMantle <br />ed Chemiat (GAC) <br />a�y <br />7C Regietmed S1,Arenmental Hearth Spedialief <br />p Professional Englneer(PEI <br />Cissa 11 Regi"t'*d EmAronmental AsaeaSdr <br />❑ Yea ❑ ryo This tank rex er mmEdSable <br />❑ CSLB IlCaneed Cant agor (won nazamo,, suhstance mrtMvtal <br />ma[edals• <br />IMICSter dw m went be,,g <br />D M9 cwquaed do the tank. <br />If yea, rpe Lank Intentor apnpaphere yrall be ro-rlteacetl riBtt a m/aeuspbb gas <br />CeroseYs folk management insbuCdpha rex ntmp dower, <br />dispose, f3c;q. er, <br />I <br />I <br />na¢t" <br />