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STATE OF CALIFORNIA Eso�RQEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> } <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> • C'I IFOM NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 410n E _ Fremont Street <br /> CITY Stockton COUNTY San Joaquin <br /> II. INSTALLATION (mark all that apply): <br /> Fw] 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 /> F*] 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 thatthe i o ation provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 11/4/98, <br /> Print Name Craig Bell Aqent for Owner Phone ( 916) 372-1985 <br /> Address 1631 Spap rt Blvd , <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ M-31 <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />