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TANK CLOSURE CERTIFICATION FORM <br /> 3 fAGUTV Id� , <br /> aU40.E5a r <br /> James" <br /> King Trust <br /> ,a. <br /> SITE AMRSSS <br /> 541 E. Harding Way <br /> ttie aueWEss Lf tae <br /> SUSIn 33 CITY Stockton, CA <br /> >ao <br /> TKovm <br /> amefEs K,4Y4i <br /> I dameng Trust <br /> TANK CVME0.AOp0.E45 <br /> C/O Jim W. Love, Trustee, 4545 Georgetown Pl. , Bldg. D <br /> $OZ STATE 103 L0. StiA <br /> TAex dwNEk GTv <br /> Stockton, CA 95207 <br /> Tank a Flammable vapor oxygen <br /> (State Tank 00.if applicable) Top Center Bottom Top Canter Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> On examination of the tank,I dertity the tank is visually free from product sludge.scale(thin.flaky residual of tank contents),rinseate and deans. I further mMrfy <br /> that the information provided herein is true and accurate to the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILUITION OF CERTIFYING PERSON <br /> CERTIFIER NAME(PRINT) sm Certifier is a representative of the CUPAIUA: YES Q NO Q <br /> CERTIFIER TITLE soT <br /> Contractor Name df CUPAIUA <br /> ADDRESS P.O. BOX 357 If certi fer is other than CUPAILIA check appropriate box bekhw: <br /> CITY Lodi CA 95241-0357 ❑ Certified Industrial Hygienist(CIH) <br /> PHONE (209)368-6175 <br /> DATE CERTIFIED spa CERTIFICATION TIME ❑ Carded Safety Professional(CSP) <br /> Q Carded Marine Chemist(CNC) <br /> ❑ Registered Environmental Health Specialist(RE'riS) <br /> ❑ Professional Engineer(FE) <br /> ❑ C:aas II Registered Environmental Assessor <br /> CSLS licensed contractor(with hazardous substance certfiwte) <br /> ❑,Yes Q Na This tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-checked wdh a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Camilefs tank management instructions for scrap dealer.disposal faality,etc <br /> A copy of this certificate shall accompany the tank to the recycingidisposw facility. <br />