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,*me STATE OF CALIFORNIA V./ pEz°�a«s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION r _ <br /> r <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 0 7 R `9 W C HA Ltj-'fl <br /> - <br /> CITY S-LQ C X to ./ COUNTY SA A) \ nA3-zQ LA t j <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> ri;,�Ty <br /> ie installation has been inspected and approved by the implementing agency. <br /> V'/ 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agents ��— Date 7 - A2 -9 <br /> Print Name )M _ Stt r{�E �S Phone ( 216 ) 6j ( —l6 Y4 <br /> Address t 2 91 �._('� /O ,a1 J (7,5 (Z G> d V.4- <br /> LOCAL <br /> /.4LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7rei) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 9 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORMC7 <br />