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TANK CLOSURE CERTIFICATION FORM <br /> CS I i I <br /> a I pAcurr io. + <br /> auauEssruuE <br /> James King Trust <br /> sms Aooass <br /> 541 E. Harding Way <br /> +as auswE;s ap :re <br /> aus esscm Stockton, CA <br /> TCANET ruwE, <br /> i names King Trust <br /> ;ot <br /> TANK awNai AMORE53 <br /> C/O Jim_W. Love, Trustee, 4545 Georgetown P1. , Bldg. D <br /> ,aj $THTC Sa3 dip <br /> rAraauwreectr CA I 95207 <br /> Stockton, <br /> 11 /NK r'+ n <br /> Tank it Flammable Vacor Oxygen <br /> (State Tank ICs.if applicable) Top Canter Bottom Top Canter Bottom <br /> Tank Interior I I / I I 0 <br /> Atmosphere <br /> Readings <br /> I <br /> On examination of the tank.I certify the tank is visualty free from protium sludge.smle(inin.Aaky residual of tank contenss),rins cats and beans. I further snify <br /> that the information provided herein is we a d actuate to me oest of my Itnowledge. i <br /> CERTIFIER SIGNATURE STATUS OR AFFILIATION OF CERTIFYING?ERSON <br /> CERTIFIER NAME(PRINT) sae Cartifier is a representative of trio CUPA4JA: YES Q NO Cl <br /> CERTIFIER TITLE sm Contractor Name of CUPAACIA <br /> ADDRESS P.O. Box 357 If certifier is other Tan CUPAILIA C+ei appropriate box below: <br /> QTY Lodi CA 95241-0357 Q Carolled Industrial Hygienist(CIH) <br /> PHONE (209)3Q9—F;1 75 Cl Canifled Safety Professional(CSP) <br /> DATE CFRTIFIEJ sait CERTIFICATION TIME <br /> Q CarBfied Marine Chemist(GMC) <br /> 3 / o o p� Q Registered Environmenal Health Speaalist(RE;5) <br /> !/ Q Protesswnal Engineer(PE) <br /> ❑ Cass It Registered Em ironmemal Assessor <br /> ffi CSLS licensed or>di(with hazardous substanc certificate) i <br /> This tank previously nail ummadle or combustible materials. If yes,the tank interior aml0sphere snau tie re-cheated with a=mdusable gas <br /> Q`Yes Q No <br /> indlmtor prior m work being conducted an me tank. <br /> Cartifiee3 tank management insoudons for smp dealer,disposal faelity.at= <br /> _ I <br /> A copy of this cermficate shall awmpany af0 1nk to Ino recyCmg/dwoasat hcliry �� <br />