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0 0 <br />Model <br />Tank and Secondary Containment <br />Assessment Document <br />This document was prepared for: <br />Company name <br />Address <br />City, California ZIP <br />Tank/system identification: <br />Include a description of the tank/tank system that is being assessed. Examples: <br />Permit by Rule system (FTU#1) or Tank No. T -10A <br />Date of inspection(s)/assessment: <br />Include all inspection and/or assessment dates. Please include any dates used <br />to confirm data or to examine changes made to tank or system as a result of <br />recommended corrections. <br />This report consists of pages. <br />PIRRAW th` -andlWachments were prepared under <br />erection or supervision in accordance with a system designed to assure that qualified p <br />roperly gather and evaluate the information submitted. Based on my inquiry of the pers _,. <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 />.,f fin g P <br />gcurate, and complete. I am aware that there are significant penalties for submitting faA <br />Engineer's name <br />License Number <br />License Type Place and sign stamp <br />Address of engineer Stamp and sign ONLY if tank/system <br />City, State Zip meets all regulatory requirements <br />Inspector name (if supervised by <br />assessor above) <br />Date stamped/signed: <br />Company Name Tank/Tank System identification <br />