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777- <br />lit, <br />�: <br />I. SITE LOCATION <br />low <br />.. <br />STATE OF CALIFORNIA .r,. <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 />STREET 3000 West Lane <br />CITY Stockton COUNTY San Joaquin County <br />II. INSTALLATION (mark all that apply): <br />The installer has been certified by the tank and piping manufacturers. <br />FXI 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 />[K 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 />Its. OATH%' I certify that the information I <br />Tank caner/Agent „_,.X V -, <br />Print Name Jay McIlrath <br />i <br />is true to the best of my belief and knowledge. <br />4 Date Jan. 10, 1998 <br />Phone (209 )--462-8707 <br />Address 14 W. Longview Ave., Stockton, Ca. 95207 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # ❑ <br />JURISDICTION # FACILITY # TANK # <br />FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAYS BLLN FILLU PREVIOUSLY FOH0035G <br />0 0 <br />