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TANK CLOSURE CERTIFICATION FORM <br /> 2 1 FAGUTY 10• , <br /> BUSINESa NAME <br /> silveria property <br /> ,o. <br /> afTE ApORE55 <br /> 1933 hiawatha avenue <br /> its ausrNEss nv ,oe <br /> ausINESS CITY <br /> Stockton ca �, <br /> TANK OKNER NAME <br /> mrs ethel silveria <br /> a, <br /> TANK CVMER AOORE55 <br /> 1933 Hiawatha avenue <br /> TANK OWNER CITY <br /> SCO $TATE 50.1 EMR :OA <br /> stockton ca 195205 <br /> Tank Q Flammable vapor Oxygen <br /> (State Tank IDS.if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> III (-PRTECATION <br /> On examination of the tank. I cenify the tank is visually free from produm sludge.scale(thin.flaky residual of tank contents).rinseate and aeons. I further ceady <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 Sas <br /> CERTIFIER NAME(PRINT) sin 4 Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑ <br /> CERTIFIER TITLE Sar geologist Name of CUPA/L1A <br /> ADDRESS 837 Shaw road If cerdfler is other than CUPAA1A check appropriate box below: <br /> CITY ❑ Certified Industrial Hygienist(CIH) <br /> PHONE ❑ Certfied Safety professional(CSP) <br /> DATE CERTIFIED sa CERTIFICATION TIME <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered EmAronmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class 11 Registered Environmental Assessor <br /> �{ CSLB licensed contractor(with hazardous substance certificate) i <br /> This tank previously hell flamm <br /> able or combustible materials. If yes,the tank interior atmosphere shall <br /> ❑Yes ❑No 6e rn-dtetlred wdh a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifiees tank management instTuctloru for sctap dealer,disposal faality,etc <br /> ust removal- <br /> A copy of this certificate shall accompany the tank to the recyctingldispasal fadliry• <br />