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STATE OF CALIFORNIA ` E5°UncES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> P <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> rt,A 7 10 0 0 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> SUPREME <br /> I. SITE LOCATION <br /> STREET 2705 country Club Blvd. <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 /> 1< The installation has been inspected and approved by the implementing agency. <br /> j 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 /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the info mati nvided is true to the best of my belief and knowledge. <br /> er pro <br /> Tank OwnDate3-26-96 <br /> Print Name Leslie Smith Phone ( 916 ) 443-0890 <br /> Address 1831 16th Street Sacramento, CA 95814 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUrnNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />