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MODEL <br /> Tank and Secondary Containment <br /> Assessment Document <br /> This document was prepared for: <br /> Company Name: San Born Chevrolet <br /> Address: 1210 Cherokee Lane <br /> City,California ZIP- Lodi,Ca 95240 <br /> Tank/System Identification: <br /> 850 Gallon Used Motor Oil Storage Tank and Collection System <br /> Date of lnspection(s)/Assessment: <br /> 11/7/2013 <br /> This report consists of S pages and 8 Attachments <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 manage 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 knowing violations. <br /> Engineer's Name: Mike Smith Engineering,Inc. <br /> License Number: 44590 <br /> License Type: R.C.E. <br /> Address of Engineer: 4.N. Main St./P.O.Box 611 rt <br /> Lodi,Ca 95240 <br /> IN <br /> Inspector name(if supervised by �. <br /> assessor above) <br /> Date Stamped/Signed <br /> RECEIVED <br /> MAR 2 7 2015 <br /> San Born Chevrolet ENVIRONMENTAL. Used oil <br /> _ HEY u nCOACT4=1611 <br />