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TANK CLOSURS CcRT1F1CATION FORM <br /> �•�• 1 x 1 <br /> 1 csrn � IrF�-Ftr,:��r�I - <br /> 3UStNE55 <br /> Services 3 I AC UTY IC <br /> s t <br /> "S P <br /> .i(c aCCRr:S '04 <br /> 3505 Navy Dr. <br /> ausINESS:P <br /> aU51NES5C:TY 'OS :06 <br /> Stockton , CA - 500 I AF9na <br /> rANK C'.vNE�WME <br /> I ST Services <br /> ,o, <br /> rANK OWNER ACCRESS <br /> -- I <br /> -2941 Navy Dr. ---- - -- - — <br /> rANK CrvNER CITY SciZ a,Aic iO3 aP 56a <br /> Stockton, CA 95206-1149 <br /> I <br /> Lj <br /> Tank z Fammaole valor Oxygen I <br /> (State Tank ICs.-if apolinaole) Top Canter Bottom Top Canter I Bottom <br /> tmnknr <br /> tospne ep� <br /> Readings <br /> I <br /> rc Ti aT+ <br /> On examination of the tank, 1 certify the tank is visually free from oroduC.sivage.scale(thin,laky residual of tank contents),rinseate and Cerus. I further certtfY <br /> that the information provided herein is true and ac=z-ate to the best of my knowieCge. L <br /> l 5TH 5 OR AFF1LlA 1CN OF C.'R i iF!1NG PERSON "c"CERTIFIER SIGNATURE <br /> i <br /> CERTIFiE.R NAME(PRINT) Certifier is a representative of the CUPA/L'A- YES Q NO <br /> CERTIFIER TITLE ;or Contractor Name of CUPA/UA - <br /> ACCRESS P.O. Box 357 If certifier is other chart CUPAIUA Ctecx appropriate box blow <br /> e : <br /> CI7'! Lodi CA ❑ Certified Industrial Hygienist(CIH) <br /> PHONE (209)368-6175 <br /> Q Certified Safety Professional(CS?) <br /> CA—i=CERT1F1ED son CERTIFiCATICN TIME <br /> Q Certified Marine Ctiemtst(C-MC) <br /> Q Registered Err-ironmental Health Specalist(RE:HS) <br /> Q Prafess:anal Engineer(PE) <br /> C Crass II Registered Environmental Assessor <br /> �I �! CSL3 Licensed comraaor(with hazardous substance CertH ccs) <br /> E§Yes Q No This taf7K previously tte!d lammacle or combustible materials. If yes.he WK interior atinosanefe snail be re-Ctecked with a comousoble g� <br /> indicator prior to work being conducted on the tank. <br /> Cariner's tanK management instruai=3 for soap dealer,disposal faCl'rty,etc <br /> None <br /> I <br /> I <br /> i <br /> A=ay of this Certificate snail ar-=moany he tank to the reCyCing/Cisodsal faciity. <br />