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TANK CLOSURE CERTIFICATION FORM <br />SUSINESSNAME <br />St. John's Episcopal Church <br />] <br />FACIUry 10• 1 <br />SITE A00RESS <br />342 N. Hunter <br />'« <br />auSINESS CITY Stockton, CA 95202 <br />+as <br />auSINESS ZIP 'da <br />TANK ONRIER NAME <br />St. John's Episcopal Church <br />SW <br />TANK ONMER ADDRESS <br />316 N. E1 Dorado St <br />sp, <br />TANK OWNER CITY <br />SM <br />STATE 503 <br />CA <br />I ZIP 501 <br />95202 <br />Tank t Flammable Vapor Oxygen <br />(State Tank IDi, if applicable) Top Center Bottom Top Canter Bottom <br />Tank Interior <br />Atmosphere <br />Readings <br />1 <br />III CIFF!"TIPIrATION <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 debris. I further certify <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 sas <br />Certifier is a representative of the CUPA/LIA: YES ❑ NO Q' <br />Name of CUPA/LIA <br />If cartiRer is anter than CUPAILIA check appropriate box below: <br />❑ Certified Industrial Hygienist (CIH) <br />❑ Certified Safety Professional (CSP) <br />❑ Certified Marine Chemist (CMC) <br />❑ Registered Ervaronmental Health Specialist (RENS) <br />❑ Professional Engineer (PE) <br />❑r� Class 11 Registered Environmental Assessor <br />[I CSLB licensed contractor (with hazardous substance certificate) <br />CERTIFIER NAME (PRINT) R10thard Thorpe <br />CERTIFIER TITLE soT <br />Contractor <br />ADDRESS P.0. Box 3bi <br />CITY Lodi, CA 9b241-0Jbi <br />PHONE (209)368-6175 <br />DATE CERTIFIED soa <br />7/24/01 <br />CERTIFICATION TIME <br />• <br />® Yes ❑ No This tank previously held flammable or combustible materials. <br />indicator prior to work being wnducted on the tank. <br />If yes, the tank interior alinosphere shall be re-rheeked with a combustible gas <br />Cartiflers tank management instructions for soap dealer. disposal facility. etc: <br />None <br />A copy of this cenificate shall accompany the tank to the recyciing/disposal facility. <br />