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STATE OF CALIFORNIA S,URCC, <br /> STATE WATER RESOURCES CONTROL BOARD wP <br /> ...... <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 2705 Country Club Blvd. <br /> CITY Stockton, Ca. COUNTY San Joaquin <br /> II. INSTALLATION (mark all that apply): <br /> E-] The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> F-1 The installation has been inspected and approved by the implementing agency. <br /> F--1 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] Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the info matio !bqvide is tru"theb.&LQf my belief and knowledge. <br /> Tank Owner Date <br /> Print Name <br /> /1 6^1 At!�P4 Phone (1qA) 411( <br /> v <br /> Address <br /> C4-, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FFI FT-1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />