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LOCAL AGENCY USE bK-.Y` <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # F <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />I. SITE LOCATION <br />STREET 3000 West Lane <br />CITY f tcackt n �`' COUNTY San Toattuin t:vulaty ' <br />II. INSTALLATION (mark all that apply): <br />The.Instatter has been certified by the tank and piping manufacturers. <br />® The installation.has been inspected and certified by a registered,profesional engineer. <br />., <br />} The ihstailation has been inspected and approved by the implementing agency. <br />] All work fisted 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 />t <br />� <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, <br />1998 <br />Print Name Jay Nfcllrath Phone (W9 ) 4#2�-8707 f..` <br />Address 141 t+t Longview Ave. Stocktoii, Ca 95207t* <br />LOCAL AGENCY USE bK-.Y` <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # F <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />