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Model <br /> Tank and Secondary Containment <br /> Assessment Document <br /> This document was prepared for: <br /> l� Company name AvrW4f r v� )Ac&eV <br /> Address <br /> City, California ZIP <br /> Lt—ank--/system identification: <br /> Ape,/% p,�vl Tat <br /> description of the tank/anksyst�� s being assessed. Examples: <br /> Rule system (FTU#1) or Tank No. T-1 DA <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 /> rproperly <br /> consists of pages. <br /> penalty of law that this document and all attachments were prepared under my <br /> upervision in accordance with a system designed to assure that qualified personnel <br /> er and evaluate the information submitted. Based on my inquiry of the person or <br /> 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 possibility of fine and imprisonment for knowin violations. <br /> Engineer's name/;rOmWlil .Z•fG�i4ry <br /> License Number 9'>'AO,//fi'p/ <br /> License Type ,fY v�t'vr�L Place and sign stamp <br /> Address of engineer <br /> �0�OX .Z? Stamp and sign ONLY tank/systemCity, State Zip 11 <br /> ©h"�4 ' meets all regulatory requirements it <br /> Inspector name (if supe .sed by <br /> assessor above) ® Darwin J.Zachary <br /> $ CWI 97041501/112024 <br /> Date stamped/signed: <br /> OserNs <br /> Odelf'.�Nl 9 366 Xmv er-z ;WA<j2-1"r <br /> Company Name Tank/Tank System identification <br />