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Afth <br /> STATE OF CALIFORNIA PESQup k,s co <br /> STATE WATER RESOURCES CONTROL BOARD �P r <br /> CERTIFICATIONOF COMPLIANCE <br /> FOR UNDERGROUND STORAGE K INSTALLATIONFORM C <br /> 4 "A <br /> • C4CIFp H NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 120 Frank West Circle <br /> CITY Stockton COUNTY San Joaquin <br /> II. INSTALLATION (mark all that apply): <br /> [: The installer has been certified by the tank and piping manufacturers. <br /> F--j 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 /> EX The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D 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 1-28-00 <br /> Print Name George Takemori Phone (916 )386-3716 <br /> Address P.O. Box 15002 Sacramento, CA 95851 <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 />