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• STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />1. SITE LOCATION <br />STREET 3000 West Lane <br />CITY Stockton COUNTY San Joaquin County I <br />I II. INSTALLATION (mark all that apply): I <br />F -X] The installer has been certified by the tank and piping manufacturers. <br />FXJ The installation has been inspected and certified by a registered professional engineer. <br />[2] The installation has been inspected and approved by the implementing agency. <br />FX -1 All work listed on the manufacturers installation checklist has been completed. <br />F7x The installation Contractor has been certified or licensed by the Contractors State License Board. <br />D 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 Date Jan. 10, 1998 <br />Print Name Jay McIlrath Phone (209 ) 462-8707 <br />Address 14 W. Longview Ave., Stockton, Ca. 95207 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 1 F1 I I IT] <br />MOM r 17/011 TUM Cf%DRA M 10TOr Af%flnfifiD A KlIrn QV 09:13RAIT A DOI IfIATI111d MOM A JL A I INI rQqTWrV WAVr- ArrN FII Fn Pprvintiql V <br />