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TANK CLOSURE CERTIFICATION FORM <br />Bpel,le55 e4ME <br />Diesel Performance, Inc. <br />a <br />FFGury io a <br />sne +QQRSSS <br />2900 E. Fremont St. <br />,e• <br />S151HESSury Stockton CA <br />'m <br />31r3rnE5aZIP 95205 'm <br />TA cwnt:,ai 9 <br />Diesel Performance, Inc. <br />SW <br />TwMK( lUitAOONESa 2804 E. Fremont St. <br />P. 0. Box 8387 <br />cion« owner carr <br />Stockton <br />soz <br />srwT< sm <br />CA <br />I am sp. <br />95208-0387 <br />Tank S <br />(State Tank IOA. if applicable) <br />Flammable Vapor Oxygen <br />Top Center Bottom Top <br />Center <br />ddttpm <br />Tank Interior <br />Atmosphere <br />Readings <br />III CF:RT1FI(-ATinN <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 decris. I further certdy <br />that the information provided herein is true and accurate to the best of my knowledge. <br />CERTIFIER SIGNATURE <br />STATUS OR AFFILIATION OF CERTIFYING PERSON am <br />Certifier is a representative of the CUPA/UA: YES ❑ NO ❑ <br />Name of CUPA/UA <br />If certifier is other than CUPAnJA check appropriate box below: <br />Q Certified Industrial Hygienist PH) <br />C2 Certified Safety Professional (CSP) <br />Q Certified Marine Chemist (GMC) <br />❑ Registered Environmental Health Specialist (RFHS) <br />Q Professional Engineer (PE) <br />Q Class II Registered EmAmmnemal Assessor <br />Q CSLS licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) soe Martin Thorpe <br />CERTIFIER TITLE sdr <br />Contractor <br />AOORESS P. 0. Box 357 <br />CITY Lodi CA 95241-0357 <br />PHONE 2 368-6175 <br />GATE CERTIFIED sm <br />CERTIFICATION TIME <br />5( Yes ❑ No This tank previously held flammable or combustible materials. <br />indicator prior to work being conducted on the tank. <br />If yes. the tank interior abmosphem shall be re-cnecl ed wdh a combustible gas <br />Caniffees tank management instcucdoas for scrap dealer, dispel facility. etc <br />A copy of this certificate shall accompany the tank to the recyCinq/disposal facility. <br />