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l <br /> STATE OF CALIFORNIA sovRces <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION ° 0. <br /> �.,. FORM C <br /> r <br /> r <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> DIESEL <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 /> 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 /> /E:1� Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the informa on provided is true to the best of my belief and knowledge. <br /> Tank Owne a Date 3-26-96 <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.# � J D <br /> 16 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br /> 0 0 <br />