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3-01-1999 2:,17PM FROM • P.13 <br />TANK CLOSURE CERTIFICATION FORM <br />Auumo� <br />s I ""';13677 <br />11us+r�ess •K+ac 13 6 7 7 91 <br />HOLLY SUGAR dba SPRECKELS SUGAR COMPANY CAD 08 <br />SM AObREs <br />20500 HOLLY DRIVE <br />�Sp <br />SUSHI cnv TRACY CALIFORNIA <br />m <br />'AWt C+.rFA ruYE <br />SAME <br />iANlk o..nsA Aooacss <br />SAME <br />SG QTASE fE3 � �' <br />TAMK Q+mBl iter <br />11 hill <br />Tank 2 Flanurtable Vaoot Oxygen <br />(Stale Tank ICC, if applicable) Too Center Sovarn Too Center 3phpm <br />Tans Interior <br />Atinosonem N/A <br />Real <br />ill nFR71FICAT TON <br />on of the tank. 1 certify die tank is visual free from product. sNdge. scale <br />ation prol herein is we and acaaate to the best of my knowledge. <br />ffCF-ITMnFIERIGNATURE N A - CLOSURE IN PLACE <br />(Nin, flaky resiatul of tank Cbftteltl rutseate and deorts. 1 firmer cerl <br />STATUS OR AFFILIATION OFCERTF"WG?SRSCN <br />Cardfler is a representative of the CJPAI-Lk VES Q NO L-'CERTIR£.R <br />Name of CUPNIJA <br />If Carol 3 omen ytan Cl cries appropriate box belw: <br />C3 al Canfled Imitti Hygieat (Cl(C <br />Q Oarrtaed Safety Professional (CSP) <br />Cl Cenised Marne Cnemis (Css(.i <br />c-cnmER NAME (PRINT) 5011 <br />TITLE soy <br />ADDRESS <br />CITY <br />PHONE <br />OATEC=- FIE0 sca <br />CERTIFICATION TIME <br />❑ Registered Emrwnmentill Heatm Speaallst (RErl <br />❑ Professional Fsgb,ew (PQ <br />Q Cast Il RegiKured F1MloM1lglpl ASSessdr <br />❑ CSI licensed mntrill (,elm ttaZardo= suostano certificate) <br />❑ Yes ❑ No This tank prev ou* <br />Indicator prior m work <br />nerd ftammaote or comle ousdi matenats. <br />being coral on the tank. <br />If yes. gte Iar1K imenor aannspnem shall be re -Check" ,Nm a m 111ible gas <br />N/A <br />Caroflers aruk management instruraona for scu deall disposal fao)ity, etc ' <br />N/A <br />A aWy of tris tarffficate shag acrLmpany the tank to gl0 rtFiculi aispos l at]l1fY. <br />MAR 01 '99 14157 PRGE.13 <br />