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TANK CLOSURE CERTIFICATION FORM <br /> a .Auury to• + <br /> BUSINESS nUME <br /> (Former) Stockton a <br /> SITE aWRESS <br /> 730 E. Channel St. BUSINESS ZIP :m <br /> BUSINESS ciT <br /> Stockton � <br /> 'AN-CY"E NAME <br /> Ra mond Investment Corp. <br /> o, <br /> TANK bWNER AOORESS <br /> 817 South Center St. sox STATE NoZIP SO" <br /> A"k QNMER 011 CA 195206 <br /> Stockton <br /> Flammable Vapor Oxygen <br /> Tank 3 Center Bottom <br /> (Slate Tank ICs.if applicable) Top Center Bottom Top <br /> Tank Interior <br /> Atmosphere <br /> Readings <br /> Faxamimation of the tank.I certify the tank is visually free from product.sludge.scale(thin.flaky residual of tank contents),rinseate and debris. I further certify <br /> rmation provided herein is true and accurate to the best of in knowledge- <br /> in STATUS OR AFFILIATION OF CERTIFYING PERSON nes <br /> CERTIFIER SIGNATURE <br /> 1 (PRINT) nos Cer9fier Is a representative of the CUPA/LIA: YES LJNO <br /> CERTIFIER NAMAE ❑ <br /> CERTIRER TITLE nor President Name of CUPAILIA 1 <br /> 1 <br /> ADDRESS P-0. BOX 95 If certifier''s other than CUPA/LIA check appropriate box below[ <br /> clTv San Andreas CA ❑ Certified Industrial Hy9lemst(CIH) <br /> PHONE _'] — ❑ Cerified Safety Professional(CSP) <br /> DATE CERTIFIED son CERTIFICATION TIME <br /> ❑ Certified Marine Chemist(GNC) <br /> ❑ Registered Environmental Healln Specialist(RFHS) <br /> Q Professional Engineer(PE) <br /> 1 ❑ Class It Registered Environmental Assessor <br /> r-y CSLB l;_Sed cormraGor(With hazardous substance certificate) <br /> L3 vs ❑No held flammable dr combustible materials. If yes.the lank interior atmosphere shall be re-checked with a combustible gas <br /> This tank previously he <br /> indicator prior fo work being conducted on the tank. <br /> Cartifiefs tank management inswctiorts tar srndp dealer,disposal facility.etc <br /> Constantly monitor LEL & 02 in tank while disposing of same. <br /> � I <br /> copy of thew"ficate stam <br /> ll accopany the lank to the necyCing/disposal facility. _� <br />