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TANK CLOSURE CERTIFICATION FORM <br /> �nw y <br /> ] FAQIJTY 10• , <br /> aU9NE55 NAME <br /> silveria property <br /> ,o. <br /> 9RE A00ftESS <br /> 1933 hiawatha avenue <br /> ,os aus,NEss Zip :x <br /> WSMESS CITY <br /> stockton ca <br /> sm <br /> TAMK OWNER NAME <br /> mrs ethel silveria <br /> TANK OWNER AOtlftESe <br /> 1933 Hiawatha avenue <br /> TANK OWNER ctTY sax sTAr sm sa. <br /> stockton ca 1av95205 <br /> Tank IS Flammable Vapor Oxygen <br /> (State Tank IDS.if applicable) Top Center Bottom Top Center Bottom <br /> Tankh <br /> Atmosphere <br /> Readings <br /> TinN <br /> on examination of the tank,I certify the tank is visually free from product sludge.scale(thin,flaky residual of tank contents),rinseate and aeons. I further certify <br /> Mac the information provided here is t and acture the best of my knowledge. <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING PARSON sos <br /> CERTIFIER NAME(PRINT) sea Cardfier is a representative of the CUPAIUA: YES ❑ NO Q <br /> CERTIFIER TITLE sor geologist Name of CUPAAJA <br /> ADDRESS 837 Shaw road If certifier is other Man CUPA/LIA check appropriate box below: <br /> CITY ❑ Cerdfied Industrial Hygienist(CIH) <br /> PHONE ;1 ❑ Certified Safety Professional(CSP) <br /> DATE CERTIFIED son CERTIFICATION TIME <br /> ❑ Certified Marne Chemist(CMC) <br /> Cl Registered Engineer <br /> nnental Health Specialist(RE'riS)(J�1/ ❑ <br /> Professional <br /> EEngiginee er(PE) <br /> Chess II Registered Environmental Assessor <br /> CSLB licensed cordractor(with hazardous substance certificate) <br /> El yes ❑Na This tank previously held flammable or Combustible matenals. ye a lank interior abnosphere shall be re-Ducked with a cembusdble gas <br /> indicator prior to work being conducted on the tank. <br /> Cantifiers tank management instructions for scrap dealer,disposal facility,etc: <br /> ust removal- <br /> A copy df MLs certificate shad accompany the tank to the recyding/disposal facility. <br />