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0 <br />STATE OF CALIFORNIA As <br />ov.•+q co <br />STATE WATER RESOURCES CONTROL BOARD P �, <br />CERTIFICATION OF COMPLIANCE 01 <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />1. SITE LOCATION <br />STREET 121 south San Joaquin <br />CITY Stockton COUNTY San :Joaquin <br />IL INSTALLATION (mark all that apply): <br />E-] 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 />PK -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 />❑ Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent San Joaquin County-411otor Pool Date 12-17-93 <br />Print Name Earl S. Gilford Phone ( 209 ) 463-3104 <br />Address 444 South Wilson Way, Stockton, California <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. #31 ��..._, ❑ I Ll 111 <br />FORM c (791) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORKS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />