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Li STATE OF CALIFORNIA %we �es�;� <br /> STATE WATER RESOURCES CONTROL BOARD �• " <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION :r � ;' <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. 0-7400 <br /> STREET 229 -5 r-li2.01I <br /> CITY L-00 1 COUNTY sAv-t JO'ACo L i,,A <br /> ll. INSTALLATION (mark all that apply): <br /> �j The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> E�X 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 /> D Another method was used as allowed by the implementing agency.*(Please specify.) <br /> Ill. OATH I certify that th ' formation=ovided true to the best of my belief and knowledge. <br /> Tank Owner/Agent A,— Date 02/28/92 <br /> Print Name Arco duct Co. - Environmental Health <br /> and S ety Dept. , Phone Ms. Judy Mason ( 310) 407-2605 <br /> Address 17315 Studebaker Rd. Cerritos, CA 90701 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# 27Z- <br /> TANK <br /> LTANK I.D.# 0 7 / <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORDXV <br />