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TANK CLOSUPE CERTIFICATION FORM <br /> c� tTv n T r <br /> 9USINE55 NAME 3 I rAC:LT1'IC f 4 <br /> The Port of Stockton <br /> SITE AOCRES3 <br /> 2201 W. Washington St . I <br /> ,cs auslNss ZIP � I <br /> allSI-ESS C,TY 95201 <br /> TANK CwNER 1AAM@ <br /> The Port of Stockton <br /> TANK C%NEA ADDRESS <br /> 2201 W. Washington St . <br /> "ANK v�+mER GITY SM 57AT'c 5a3 Z:;' -� <br /> Stockton , CA 95201 <br /> 11 14 4K ru-;UP5 M41P, <br /> TanK 1 Fiammahie'aapor Oxygen <br /> (State Tank Z-A. if appiicablel Top Center Eottam Toe Center 3ortom <br /> 7ankInterior <br /> Atmospheree <br /> Reauings <br /> 4 � <br /> I <br /> P7 1 Tl <br /> On examination of the tank, 1 certify t art visa orfs tic.sludge. scale(thin. 'laky residual of tank;=ienw,nnseate and aeons. 1 further mortify <br /> that the information prevlded herei t nd ac pf my''<nowledge. <br /> I <br /> CERTIFIER SIGNATURE STATUS QR AFFILIATICN OF CERTIF'ING :)C?SGN 5 <br /> CERTIFIER NAME(PRINT] toe Richar ���eCarufier is a representative of;he G JPA/LIA: YES ❑ *t0 <br /> CERTIFIER TITLE soy <br /> Contractor Name of CUPAJLIA <br /> AOCRESS P.0. Box J If certifier:s other than CUPA UA ctecdt approonate box below: <br /> Lodi CSTV Lod , 77F93 ❑ Certrfied Industrial Hygserlrst(CSH) <br /> PHONE (209336t�]-- J <br /> !DATE CERTIFIED sae CERTIFICATICN TIME C3 Certified Safety Professional{GS?} <br /> ❑ Certified Manne C%emtst iCMC) <br /> 1/4/99 1 PM <br /> 3 <br /> ❑ Registered Environmental Health Specatist;RE�S) <br /> t <br /> ❑ Professional Engineer(PE) <br /> S ❑ C:ass II Registered Environmental Assessor <br /> t <br /> CSL9 licen5ed C31"tYdCor(with hazardous SubStanCe cert,ficate) <br /> i. ® "es ❑ No Thts tank previously held flammable or combustible matenals. if yes, the tank interior atmosphere shall be m-�secxed with a cnmousvble gas <br /> indicator pnor to work being conduced on the tank. <br /> 4 Certifier's taynK management Instrucions for scar,dealer,disposal!aciity,etc: <br /> t <br /> I A copy of this certificate shalt accomoany the tank to the recjCingldisoosal`amity. <br />