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d , <br /> STATE OF CALIFORNIA ............. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> t "4 ;� CERTIFICATION OF COMPLIANCE t <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION as <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> T t I.SITE LOCATIONk. <br /> STREET 120 Frank West. Circ <br /> R CITY _ Stockton COUNTY San Joaquin <br /> - - <br /> II. INSTALLATION (mark all that apply): } <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 atfiproved by the implementing agency. <br /> '* F-A 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 /> , <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 G'earc a Takemori Phone (916 )386-37:16 <br /> Address P.O. Box 15062 Sacramento, CA 95851 <br /> LOCAL AGENCY USE ONLY <br /> STATE CbUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c� <br /> rte£ - <br />