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STATE OF CALIFORNIA Egoo,Oes <br /> STATE WATER RESOURCES CONTROL BOARD P" •" `�.�^ <br /> x [ CERTIFICATION OF COMPLIANCE <br /> C � i rl I {'..i� 1 Nii� �I�.�i.I S e <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> DEQ' 2 ) NM 9' 51 FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 3'J4 t�AST MAN ST: <br /> CITY 11R tPON' COUNTY SA4 JOAQUIN <br /> II. INSTALLATION (mark all that apply): <br /> �he installer has been certified by the tank and piping manufacturers. <br /> F-1 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 /> d All work listed on the manufacturer's installation checklist has been completed. <br /> �he 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 490-16e0A) Date JZ 1419S <br /> Print Name R • (�'j}(t/Z�r-r ^ ftrnj. pgrAll-S I)ESJC Phone (5'jb ) <br /> Address D, 13 <br /> ox SM Z'9SaC7 <br /> R"04 r c-0 0)46F 3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# M <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0075C7 <br />