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Model <br /> Tank and Secondary Containment <br /> Assessment Document <br /> This document was preparedfor: <br /> Company name,6Fvr'N•r 7577va/f 9 7'Wj*;/.e4*4 <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 inspections)/assessment: '0?O <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. II <br /> This report consists of _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, including the-.-ssibility of fine and imprisonment for knowing violations. <br /> Engineer's name <br /> License Number <br /> License Type Sri^vGrv!^ �C Place and sign stamp <br /> Address of engineerp� Stamp and sign ONLYif tank/system 1i <br /> City, State Zip . 6oX-usy meets all regulatory requirements it <br /> "A-�sCX e . II <br /> Inspector name (if supervised by II <br /> assessor above) Darw;n I Z8chary <br /> 9700501 <br /> r4 <br /> W EXP• 41112024 <br /> 3 <br /> Date stamped/signed: <br /> ,-o'C vdc 7'4Xk <br /> Ciz. <br /> Company Name <br /> Tank/Tank System identification <br />