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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE w u <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION > <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MAY 15 1992 ~ <br /> ENVIRONMENTAL HEAL H <br /> I. SITE LOCATION <br /> PERMIT/SERVICES <br /> STREET 2650 NORTH MAC ARTHUR DRIVE <br /> CITY TRACY COUNTY SAN JOAQUIN <br /> II. INSTALLATION (mark all that apply): <br /> X 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 /> F-� 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 7 _ Date 5/13/92 <br /> Print Name HARRYFI HER Phone (408— ) 365-2691 <br /> Address 6450 VIA DEL ORO, JOSE, CA 95119 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FA�CIILITY# TANK# <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 FOR005c7 <br />