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STATE OF CALIFORNIA ego YAne <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 ARCO FACILITY NO. 0-7400 <br /> STREET 2.2_� -,e�. rHZZOYEE ►—A .1E <br /> CITY 1,001 COUNTY SQr l .)oac�u r l <br /> Il. 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 /> [� The installation has been inspected and approved by the implementing agency. <br /> [:R All work listed on the manufacturer's installation checklist has been completed. <br /> [:R 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 th ' formation z0vided true to the best of my belief and knowledge. <br /> Tank Owner/Agent A— Date 02/28/92 <br /> Print Name Arco duetyct Co. – EnvironmentMs- Judy Ma 5al HealthPhone ( 10) 07-2605 <br /> and .Address 17315 Studebaker Rd. Cerritos, CA 90701 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# f TANK# .G� <br /> TANK I.D.# K I 1� I I I I I I I fl 61�s/4�_ <br /> FORM C(791) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY F0110075C7 <br /> `/ `J <br />