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MODEL <br />Tank and Secondary Containment <br />Assessment Document <br />This document was prepared for: JAIN <br />Company Name: Tracy Unified School District <br />, <br />Address: 1975 West Lowell Ave.'` <br />A <br />City, California ZIP: Tracy, Ca 95376 <br />Tank/system identification: Used Oil <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 Inspection(s)/Assessment: <br />12/1/2011 <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 13 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 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. SS/ <br />License Number: 44590 <br />License Type: R.C.E. <br />Address of Engineer: 4. N. Main St./P.O. Box 611 <br />Lodi, Ca 95240 it <br />4. C <br />Inspector name (if supervised by i'l EX. 3- -12 <br />assessor above) <br />Cl V 11, <br />OF <br />Date stamped/signed <br />2 "j, 2012 <br />N AAJTE-iN'TAL <br />F PAPi T P!Fn <br />Tracy USD Tank/Tank System Identification: Used Oil <br />