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TANK CLOSURE CERTIFICATION FORM <br /> ausIME55 w.YE 1 FAULTY id• r <br /> Safeway, Inc. 2707 <br /> srtE AcoREss 10A <br /> 6425 Pacific Ave. <br /> WSINESS CITY Its auswEss ap 10e <br /> Stonkton , CAr <br /> TANK dERr a SW <br /> wN <br /> Safeway, Inc. <br /> TANK dwNEIt AoaREss 301 <br /> 5918 Stoneridge Rd. <br /> TANK CWNER CITY 502 VAT'c 503 IIP 50A <br /> Pleasanton , CA 95488 <br /> 11 TAW (-.1 QqI IRE INFQRMA:Ql`)N <br /> Tanks Flammable Vapor Oxygen I <br /> (State Tank ICs.if applicable) Top Center Bottom Top Center Bottom l <br /> i` <br /> Tank Interior I <br /> Atmosphere <br /> Readings j <br /> III_ cpqTIFTcATinN <br /> On examination of the tank.I certify the tank is visually tree from product,sludge.scale(thin.flaky residual of tank wmems),rinseate and deons. I further anify <br /> that the information provided herein is time and ac=he to the bast of my knowledge. <br /> CERTIFIER SIGNATURE <br /> STATUS OR AFFILIATION OF CERTIFYING PERSON acts <br /> CERTIFIER NAME(PRINT) soe ar tri Tnorpe Certifier is a representative of the CUPA/LIA: YES ❑ NO C <br /> CERTIFIER TITLE 507 contractor Name of CUPAAIA <br /> ADCRESSP.0. Box 357 If certifier is other than CUPAJUA check appropriate box below: <br /> CITY Lodi - ❑ Carded Industrial Hygienist(CIH) <br /> PHONE _ 75 <br /> DATE CERTIFIED sae CERTIFICATION TIME Q Certified Safety professional(CSP) <br /> ❑ Carded Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RETS) <br /> ❑ Professional Engineer(PE) <br /> ❑ C:ass 11 Registered Environmental Assessor <br /> Q CSLS licensed contractor(with hazamrcus substanm dar>innaate) <br /> Yes Q Na Thls tank previously held flammable or combustible materials. If yes.the tank interior atmosphere shall be re-checked with a combustible gas <br /> Ej indlcator prior to wank being conduced on the tank. <br /> Camfier's tank management instructions for scrap dealer.disposal facility,etc <br /> None <br /> A copy of this certificate shall accompany the tank to the recyctmg/disposal facility. <br />