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STATE OF CALIFORNIA %we sso°"«a <br /> STATE WATER RESOURCES CONTROL BOARD „e '�� <br /> CERTIFICATION OF COMPLIANCE ° <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. 07(oO <br /> STREET 22._S r-KLeOKEE 1 A^1E <br /> CITY 1-001 COUNTY .1C>EnoirA <br /> IL INSTALLATION (mark all that apply): <br /> L-9 The installer has been certified by the tank and piping manufacturers. <br /> E] The installation has been inspected and certified by a registered professional engineer. <br /> [:R The installation has been inspected and approved by the implementing agency. <br /> E_2 All work listed on the manufacturer's installation checklist has been completed. <br /> [-X The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> E-] Another method was used as allowed by the implementing agency. '(Please specify.) <br /> 111. OATH I certify that th ' formation p ovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 02/28/92 <br /> Print Name Arco oduct �hone Co. - Environmental HealtY <br /> andetMI)eVtMs. JudM ( 310) 407-2605 _ <br /> Address 17315 Studebaker Rd. Cerritos, CA 90701 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILnY# TANK# <br /> TANK I.D.# � L_L_L J.T ow <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A S 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROC]5C7 <br />