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TANK CLOSURE CERTIFICATICN FCRM <br /> 1 <br /> aAciuxio. t <br /> au ss VE <br /> 'moonyNAJockovich Trust I <br /> 0 <br /> sITE+dd0.F¢c <br /> 767 N. Alpine Rd. <br /> au� � ton, CA ws ausiNEs 215 10° <br /> sw <br /> TANK OWNER NAME <br /> Tony Jockovich Trust <br /> pt <br /> ITANK bwNE0.ApdRESa <br /> 8567 63: ford-Rd; -- - <br /> rANK bwsvER em <br /> sax srAr sm ar sa. <br /> Stockton, CA 95215 <br /> a <br /> Tank at Flammable vapor Oxygen <br /> (State Tank JOS.if applkable) Top Center Sodom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> On examination of the tank. I certify the tank is visually free from product.sludge.scale(thin,flaky residual of tank WntWts),mu;eate and deorts. I further cer; <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 $0s <br /> CERTIFIER NAME(PRIMA sae a.r In =if <br /> Certifier is a representative of the CUPA/LIAA YES ❑ NO Q <br /> CERTIFIER TITLE sok <br /> NContractorame Of CUPA/W1 <br /> ADORESS certifier is Other than CUPA/UA check appropriate box below: <br /> CITY Q Certified Industrial Hygienist(CIH)PHONE — Q Canified Safety Professional(CSP) <br /> DATE CERTIFIED sas CERTIFICATION TIME <br /> Q Certified Monne Chemist(CMC) <br /> ❑ Registered Environmental Health Speaal"tst(REHS) <br /> ❑ Professional Engineer(PE) <br /> ❑ Ctass 11 Registered Environmental Assessor <br /> ❑ CSLS licensed contractor(with hazardous substan2 Certificate) <br /> Yes 13 No This tank previously hell flammable or combustible materials. If yes.the tank interior atmosphere shad be re-Ceded s <br /> with a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartiflees tank management instructlone'of soap dealer.disposal facility,etc <br /> A copy of this Certificate shall accompany the tank to the recydingfdisppsal facility. <br />