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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 />I. SITE LOCATION <br />STREET 3000 West Lane <br />CITY Stockton COUNTY San Joaquin County ; <br />INSTALLATION11. .p• <br />ESpV Rc63 <br />9 <br />3 � <br />fea�� <br />6 �A <br />• C1[IFOM NSP <br />® 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 />® 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 Date Jan. 10 1998 <br />Print Name Jay Mcllrath Phone (09 ) 462-8707 <br />Address 14 W. Longview Ave., Stockton, Ca. 95207 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # �jFA�CILITY # TANK # <br />TANK I.D. # FF F -177I Ill—= — <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0635C7 <br />