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STATE OF CALIFORNIA eoVwc6s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM <br /> CC<CifaR NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> L SITE LOCATION <br /> STREET 1777 West Yosemite <br /> CITY Manteca COUNTY San Joaquin <br /> IL INSTALLATION (mark all that apply): <br /> I <br /> 0 The installer has been certified by the tank and piping manufacturers. <br /> F-1 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 w used as allowed by thp implementing agency. (Please specify.) <br /> �lCa 3 <br /> ((LOATH I certify that the in tion provided t tr a to the b st of my belief and knowledge. <br /> Tank Owner/Agent Date /6 �3 <br /> Print Name e- a u - Phone ( ) 5461 17fS <br /> Address ` Se <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FF <br /> FORM C(791) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> c0ii-lAoft--tar- <br />