Laserfiche WebLink
STATE OF CALIFORNIA �yO�a°ES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE w use <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> s o <br /> { pr,;. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> UNLEADED <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 /> 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 /> E:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the informati provided is true to the best of my belief and knowledge. <br /> Tank Owne AgentT Date3-26-96 <br /> Print Name Leslie Smith Phone (916 )443-0890 <br /> Address 1831 16th Street Sacramento, CA 95814 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />