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STATE OF CALIFORNIA PEgoVwc^S o0 <br /> STATE WATER RESOURCES CONTROL BOARD e- <br /> CERTIFICATION OF COMPLIANCE w ,� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 4100 E . Fremont Street <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 /> 0 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 /> ❑ Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111111. OATH I certify that the in r ation provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 11/4/93 <br /> Print Name Craig Sell - Agent for Owner Phone ( 916 )372-1985 <br /> Address 3 6 3 3 S ea pnt^t- B 1 vd_ <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# 0-7 <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 />