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• 10 RECEIVED <br /> OCT 21 2013 <br /> Tank and Secondary Containment ENVIRONMENTAL <br /> Assessment Document HEALTH DEPARTMENT <br /> This document was prepared for: <br /> Lodi Unified School District <br /> 820 S. Cluff Avenue <br /> Lodi, CA 95240 <br /> i <br /> Tanklsystem identification: Used Antifreeze Tank <br /> Date of inspection(s)/assessment: 10/4/13 <br /> This report consists of six (6) pages. <br /> I certify under penalty of law that this document and all attachments were prepared under my <br /> direction or supervision in accordance with a system designed to assure that qualified personnel <br /> properly gather and evaluate the information submitted. Based on my inquiry of the person or <br /> persons who mange the system,or those persons directly responsible for gathering the <br /> information,the information submitted is, to be the best of my knowledge and belief,true, <br /> accurate,and complete. I am aware that there are significant penalties for submitting false <br /> information,includin the possibility of fine and imprisonment for knowing violations. <br /> Tom Mitchell <br /> California License #C52599 <br /> Civil EngineeroyROFESSI �o? oD SS / 9l <br /> 14256 Doolittle Drive Tc y <br /> San Leandro, CA 94577 rno <br /> F" 26178 it }' 2 9 A <br /> EXP. <br /> �gCFCAt1F� sTq OFCA��F���\� <br /> Date stamped/signed: 10/21/13 <br /> Lodi Unified School District Used Antifreeze Tank Assessment <br />