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Model <br /> Tank and Secondary Containment <br /> Assessment Document <br /> This document was prepared for: <br /> Company name ,Ovr'N.r <br /> Addressp �(3OX q <br /> City, California ZIP , <br /> *',`,'®,✓/ <br /> Tank/system identification: <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 inspections)/assessment: �� _�pz <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 re ort consists of pages. l <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, including the possibil"1111:1 of fine and imprisonment for knowin violations. <br /> Engineer's name <br /> License Number <br /> License Type ^vGrv��,L Place and sign stamp <br /> Address of engineer,,o0 ,e,914.;XyStamp and sign ONLYif tank/system <br /> City, State Zip meets all regulatory requirements <br /> pt36/ <br /> Inspector name (if supervised by <br /> assessor above) Darwin I Zachary <br /> , ... ws cwi s7oa,5uzao <br /> QC1 EXP.4 <br /> Date stam ed/si ned: <br /> x sr <br /> Company Name Tank/Tank System identification <br /> l <br />