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TANK CLOSURE CERTIFICAIICN FORM <br /> I Fdryl ITv IC"PU'IF'nnT1C1N <br /> BUSINESS NAMC 3 FAC:LT 10 <br /> Van De Pol E nterprises <br /> SITE ACCRESZi w <br /> 3230 N. West Lane <br /> aust5ft-kton, CA <br /> TANK C'NNEvi.W ME Soo <br /> Van De Pol Enterprises <br /> TANK�/ ER ACCRE'SS idf <br /> P.O. Box 1107 <br /> TANK INNER C:Tv saz STATE so3 7a io• <br /> Stockton, I CA I 95241- 11071 <br /> Tank;t F;ammacle•/acor Oxygen <br /> (State Tank IC3.if aopiipolel Too Cancer Bottom Top Center dottcm <br /> Tank!nterior <br /> Atmosonere <br /> Readings <br /> n TI t -lr, <br /> On examination of the tank.I cera to is visually free from product.sludge.scale(thin, 9aKy residual of tank contemn),nnseate and aeons. I further cer,Ty <br /> that the information provided ne and accurate tote oast of my knowledge. <br /> CERTIFIER SIGNATURE I SASS DR AFFLIATICN OF C`RTIFf!NG PSRSCN :c5 <br /> LCERTIFIER NAME(PRINT) Ison K 1 Car orpe 1 Certifier is a representative of the CUPAAjA: YES Q NO CL: <br /> CERTIFIER TITLE sm ContractorI <br /> Nar,.e of CUPA/LA <br /> ACCR°SS .• <br /> CIT' P B !f cenfler s other than C'Jp.aiLlA chectc apprdonate oax below:Lndi . CA 95241-0357 <br /> 1 <br /> PHONE Carded Industrial Hygienist(C;H) <br /> DATE CERTIFIED sae CERTIFICATICN TIME ❑ Cartified Safety Professional(CSP) <br /> CC X!/ ❑ <br /> Certified Manne Cnemist(C:00, <br /> :Registered cr,ironmental Health Specalist(RE-S) <br /> ❑ Professional Ergmeer(PE) <br /> Cass II Registered Environmental Assessor <br /> CSL3 licensed cntracor(with mm3rdcus sucstance centfic+te) <br /> C�(Yes ❑ No This tank previously held 9ammacle or comoustole materials. If yes.the tank interior atmospnere snail ce r =ecxed with a-mcusuble gas <br /> indicator prior to work being conducted on the tank. <br /> DaRlnefa tank management'n5'JLGOr15`dr scan dealer,disposal raclity,etc: � per, <br /> uaru <br /> DEC 21 1998 <br /> aVl , nl L HEALTH <br /> A Cooy of tris certificate snail accompany;he:arx:o he recfcing/Cisccsai`aciity. 1 <br />