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TANK CLOSURE CERTIFICATION FORM <br /> BUSINESS NAME 1 FACIUTY 100 r <br /> The City of Stockton <br /> SITE a001`i <br /> 1Bt <br /> 428 E. Fremont St . <br /> BUSINESS CITY 105 auSINESS DP t� <br /> TANK OWNER NAME Stockton , CA QQ2 <br /> The City of Stockton <br /> TANK OWNER ADDRESS W1 <br /> 445 N. Eldorado St. <br /> TANK OWNER CITY = STATE BOT bP 5CA <br /> Stockton CA <br /> 11 TANK IOStIREINEORMADQU <br /> Tank s Flammable Vapor Oxygen <br /> (State Tank IDi.If applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III (,'F=RTIFfrATIQN <br /> On examination of the tank. I certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank contents),nnseate and debris. I further certify <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PERSON Bcs <br /> CERTIFIER NAME(PRINT) s Martin Thorpe Cartifier is a representative of the CUPARJA: YES ❑ NO ❑ <br /> CERTIFIER TITLE sot, <br /> Contractor Name of CUPAfLIA <br /> ADDRESS P.O. Box 371 <br /> CITY O 1 B _ If certifier is other than CUPAIUA check appropriate box below: <br /> PHONE -368-617b ❑ Cended Industrial Hygienist(CIH) <br /> DATE CERTIFIED sda CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(REFiS) <br /> ❑ Professional Engineer(PE) <br /> ❑TClass 11 Registered Environmental Assessor <br /> L`t; CSLB licensed contractor(with hazardous substance certificate) <br /> Yes ❑No This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Canifiefs tank management instructions for soap dealer.disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />