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Model <br /> Tank and Secondary Containment <br /> Assessment Document <br /> This document was prepared for: <br /> Company name <br /> Address <br /> City, California IP <br /> Tank/system ide tification: <br /> Include a desc ption of the tank/tank system that is being assessed. Examples: <br /> Permit by Rule s stem (FTU#1) or Tank No. T-10A <br /> Date of inspectin(s)/assessment: <br /> Include all inspe tion and/or assessment dates. Please include any dates used <br /> to confirm data to examine changes made to tank or system as a result of <br /> recommended c erections. <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 Ovaluate 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 info ation submitted is, to be the best of my knowledge and belief, true, <br /> accurate, and compl, te. 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 <br /> License Number <br /> License Type Place and sign stamp <br /> Address of engin er 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 />