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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 Road <br />2) 4, vOo 6-4--c.- a n A- i U Kl <br />CITY Stockton, Ca COUNTY San Joaquin <br />II. INSTALLATION (mark all that apply): <br />M 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 />❑ Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the informati <br />Tank Owner/Agent <br />Print Name Heng CHER <br />Address 2 <br />E. Waterloo <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # F7 <br />rovided is true to the best of my belief and knowledge. <br />rk,C__ Date Z� <br />i- —IZ— <br />Phone ( 209 ) 463 4114 <br />ad, Stockton. California 95205 <br />JURISDICTION # FACILITY # TANK # <br />MI I I I I I I I <br />nw rvnm mva or. n%.wmrN u or rcnmi ArruKAi ivry tunMs A tl UNLtSS 1NEY BEEN FILED PREVIOUSLY FOR0035C7 <br />