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TANK CLOSURE CERTIFICATION FORM <br />P. 1 M f <br />Ty inFN7FICATlQN <br />3 :acurvtds <br />ausHess-YE <br />The City of Stockton <br />,a <br />srE ,oanEss <br />428 E. Fremont St. <br />cos aus:.Ess nv +m <br />eusnEw utt <br />— <br />soca <br />r1MK P `Ut r e <br />The City of Stockton <br />r/.MK :N•NEii aacaE55 <br />o, <br />445 N. Eldorado St. <br />TAMK P+'/ME0. ctt <br />sr..,a I ZIP,p <br />Stockton <br />C - <br />Tank x <br />(State Tank ICx, if applicable) <br />Flammable vapor Oxygen <br />Top Cen[er Bottom Top <br />Canter <br />dadom <br />Tank Interior <br />Atmosphere <br />4 <br />/N6/71`�/vJ <br />Q O <br />Q <br />Readings <br />III C-PRTIFICATtnN <br />On examination of the tank. I certify the tank is visua free tra rodu=, sludge. scale (thin, flaky residual of tank contents). nnseate and aeons. I further certify <br />that the information provided herein is t e o est of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON eco <br />Certifier is a representative of Ne CUPAiLA: YES Cl NO ❑ <br />Name of CUPAlLIA <br />If certifier is aNer Nan CUPA/l1A check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marne Chemet (CMC) <br />❑ Registered Environmental Health Specialist (REFiS) <br />Cl Professional Engineer (PEI <br />CERTIFIER NAME (PRINT) sos art in Thorp_e <br />CERTIFIER TITLE son <br />Contractor <br />ACCRESS P.O. box J <br />CITY Lodi, — <br />PHONE — <br />CA TE CERTIF ED ���^^^ <br />�� / <br />/ <br />CERTIFIGttION TIME <br />OD <br />❑i Cass 11 Registered Em ironmental Assessor <br />• <br />l`S CSL8 licensed conoaCor (with hazardous substance certificate) <br />® This tank previously, held flammable or combustible materials. <br />Yes ❑ No <br />indicator prior to work being conducted on the tank. <br />ga <br />If yes. the tank interior atmosphere stall be re-dteated with a combustible s <br />Cemfiers tank management instructions for s=ap dealer. disposal fatality, etc <br />A }'fi h II nam an roo rink m Mn n llinddisoasal fac itv. <br />copy o tots cem peas a ac p y <br />