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r C r'HE <br /> AUG 1 1 2017 <br /> Model <br /> Tank and Secondary Containmer!INVIRONMENTAL HEALTH <br /> Assessment Document DEPARTMENT <br /> This document was prepared for: <br /> SANBORN CHEVROLET <br /> 1210 Cherokee Lane <br /> Lodi, CA 95240 <br /> Tank/system identification: <br /> This is a standalone pour over the top storage tank for Used Anti Freeze. <br /> There are no pumps, piping, or ancillary equipment. No discrepancies were <br /> noted at this time <br /> Date of inspections)/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 11 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, includin2 the eossibility of fine and imprisonment for knowing violations. <br /> Jordan K. Baldwin <br /> Lic#C71646 S51ONAL <br /> CA Civil PE QQ�OPN K sq �Fq <br /> 2522 Grand Canal Blvd. .� <br /> Suite 14 * 716 6 <br /> Stockton, CA 95207 <br /> 1P 01v1 <br /> F OF Cpt\F�Q <br /> Date stamped/signed: 8/1/17 <br /> Sanborn Chevrolet Used Anti Freeze <br /> 1 <br />