Laserfiche WebLink
STATE OFCALIFORMA fbo ccs <br />STATE WATER RESOURCES CONTROL BOARD A�' •" `°� <br />CERTIFICATION OF COMPLIANCE 301 <br />FOR UNDERGROUND STORAGE TANK INSTALLATION w �° <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />1 <br />STREET 2512 E. Waterloo Road KJLJ 5- ocD L_ F <br />CITY Stockton, Ca COUNTY San Joaquin <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 approved by the implementing agency. <br />Q 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 was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the inforprovided is tr to the best of my belief and knowledge. <br />mation <br />Tank Owner/Agent Date <br />Print Name Heng CHEAPhone ( 209) 463 4114 <br />Address 2512 E. Waterloo Road, Stockton, California 95205 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # <br />- - • <br />—w rvnm,rwa, or mo%owmrg oT rcmim i ArrLII:AI WN rUKMb A& is UNLE55 I HET f BEEN FILED PREVIOUSLY FOR00350 <br />