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STATE OF CALIFORNIA <br /> '"Pe STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION '•s .; <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET / 7 5�`7 I.J C I J4 R :t 7 <br /> CITY -T ZL)r; k 1) r,/ COUNTY -S A i.) J 0,�, C, u 0 nJ <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 /> lt�The installation has been inspected and approved by the implementing agency. <br /> �ZAll 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent —�G� -- Date 9 �{ 2 �j 7 <br /> Print Name S(�1# rs Phone (9'/6 ) 631 — s y,6 <br /> Address---1(��� ? �'a/6 .+1 r �� �� Nc Ne) u f/vR- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> G <br /> FORM C pied THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR 5V <br /> NW 'ft% <br />