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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET 2512 E. Waterloo Roadrh? <br />CITY Stockton, Ca COUNTY San Joaquin <br />II. INSTALLATION (mark all that apply): <br />'Ebpywt•t5 C <br />3 <br />W � V <br />• C�LI.UP �•' <br />V 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 />[ 0 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 />O Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the information <br />Tank Owner/, <br />Print Name <br />CHEA <br />is true to the best of my belief and knowledge. <br />v <br />Address 2�1� E. Waterloo Road, Stockton, California 95205 <br />LOCAL AGENCY USE ONLY <br />Date <br />Phone ( 209) 463 4114 <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 7� LI 1_1I I <br />- • i nw rvnm awa i or m%,wmr* oT rtnml I ArrLII:AI wN 1-UKM A & IS UNLL55 THEY 6 <br />BEEN FILED PREVIOUSLY FORO035C7 <br />