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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �40" .Fs <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION p <br /> FORM G <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 707 Roth Rd . <br /> ClY Lathrop COUNTY San Joaquin <br /> K4A <br /> ll. INSTALLATION (mark all that apply); <br /> r ,I The installer has been certified by the tank and piping manufacturers.. <br /> Ej The installation has been inspected and certified by a registered professional engineer. <br /> The installation has been inspected and approved by the implementing agency. <br /> l All work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATI certify that t,4a4nw4fation provided is true to the best of my belief and knowledge. <br /> Y <br /> Tangy Owne Agen Date <br /> Print Name Keith A . Tallia Phone L209 } 754-1808 <br /> Address P . O . Box 950 , San Andreas , CA 95249 <br /> LOCAL AGENCY USE ONLY <br /> I <br /> STATS COUmNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.�. <br /> FORM C {7re1} THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />