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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET 701 E. CHARTER WAY <br />CITY STOCKTON <br />II. INSTALLATION (mark all that apply): <br />COUNTY SAN JOAQUIN <br />® The installer has been certified by the tank and piping manufacturers. <br />❑ The installation has been inspected and certified by a registered professional engineer. <br />Fx:] The installation has been inspected and approved by the implementing agency. <br />® 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 />E qOU 4rES <br />111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Age �` 04/i% -imp — - Date 5-19-98 <br />Print Name KHALDOON OTHMAN Phone ( 209) 467-0305 <br />Address 701 E. CHARTER WAY _ ST_OrCKTON__CA. 95-20-6 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ I I I I III I I <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />