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STATE OF CALIFORNIA �spuwces <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION LI C <br /> UNDERGROUNDFOR T INSTALLATION4 n <br /> o . <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET1810 E. HAZELTON AVE. <br /> CITY STOCKTON COUNTY SAN JOAQUIN <br /> II. INSTALLATION (mark all that apply): <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 /> ® 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 /> III. OATH I certify that the information rovi a is true to the best of my belief and knowledge. <br /> Tank Owner/Agent SAN JOAQUIN COUNTY DEPT OF PUBLIC WORKS Date 04/16/99 <br /> Print Name EARL S. GILFORD ! Phone ( 209 )468-4104 <br /> Address 1810 E. HAZELTON AVE. STOCKTON, CA <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D. LLJ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />