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} STATE OF CALIFORNIA eovROEs <br />E <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />• CQCIFOR N' <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 />1 II. INSTALLATION (mark all that apply): <br />0 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 />M The installation has been inspected and approved by the implementing agency. <br />0 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 />0 Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent ` Date Jan. 10, 1996 <br />Print Name Jay cllrath Phone (-09 ) 462-8707 <br />Address 14 W. Longview Ave., Stockton, Ca. 952071 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # 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 FOR0035C7 <br />