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00 STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ' ESpvgcEs <br /> ...APP euRarq cp�p <br /> CERTIFICATION LI FOR ° <br /> UNDERGROUNDINSTALLATIONFORM C <br /> • C�Cicpq NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 1810 E. HAZELTON AVE. <br /> CITY STOCKTON COUNTY SAN JOAQUIN <br /> II. INSTALLATION (mark all that apply): <br /> [X] 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 /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information provided 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 al Phone (209 } 468-3104 <br /> Address 1810 E. HAZELTON AQ STOCKTON, CA <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F I I I:T1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />