Laserfiche WebLink
TANK CLOSURE CERTIFICATION FORM <br /> FA <br /> allSINESS NAME s r•ACluty io. + <br /> The Stockton Record <br /> SITE adcRESS <br /> ,o. <br /> 530 E. Market St . <br /> BUSINESS CITY +053USiN ypo2 .05 <br /> Stockton, f[� <br /> TANK OWNER NAME <br /> Stockton Newspapers, Inc. <br /> I <br /> TANK WNER ADORES$ Sol <br /> O <br /> P.O. Box 900 <br /> TANK OWNER CITY 502 STATE 500 IIP <br /> Stockton, CA CA 95201 <br /> I <br /> Tank x Flammable vapor Oxygen <br /> (State Tank IO*.if applicable)� . Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> Ili i <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 deOriS. I further certify <br /> that the information provided herein is true and accurate to the oest of my knowledge. <br /> STATUS OR AFFILIATION OF CERTIFYING PERSCN Scs <br /> CERTIFIER SIGNATURE <br /> CERTIFIER NAME(PRINT) M"t in Thorpe Certifier is a representative of the CUPA/LIA: YES C] NO <br /> CERTIFIERTITLE 507Contractor <br /> Name of CUPAlLIA - <br /> AOORESS P.O. BOX 357 if certifier is other than CUPA/LIA check appropriate box below: <br /> cITY Lodi, CA 95241-0357 ❑ Certified Industrial Hygienist(CIH) <br /> PHONE(209)368-6175 <br /> DATE CERTIFIED soe CERT1FiCATION TIME C3 Certified Safety Professional(CSP) <br /> ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RE-iS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Class II Registered Environmental Assessor <br /> CSLB licensed contractor(with hazardous substance certificate) <br /> clYes C1No This tank previously held flammable or combustible materials. If yes,the MnK interior atmosphere shall be re-cnecked with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Certifier's tank management instructions for scrap dealer,disposal faelity,etc <br /> None <br /> A copy of this certificate shall accompany the tank to the reeycting/disposal faaiity. —� <br />