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uy1A }Iw t'-er-P- ZS -,5 6 <br />STATE OF CALIFORNIA e <br />STATE WATER RESOURCES CONTROL BOARD "`°•••+e <br />t� CERTIFICATION OF COMPLIANCE e <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />o <br />SEP 0 2 1994 FORM C <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION p <br />STREET —5627 e sir tL�7+� Ay1; t wy: <br />CITY 'M��OtJ, COUNTYl Ari1E)AQ-41 to <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 />[j;�41he installation has been inspected and approved by the implementing agency. <br />ZAII work listed on the manufacturer's installation checklist has been completed. <br />[q" 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 infion provided is true to the best of my belief and knowledge. <br />70 01 <br />Tank Owner/Agent Date % <br />Print Name S Phone (f09 )116q 00,3,U <br />Address T ` <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# JURISDICTION# FACILITY# TANK# <br />TANK I.D. # IE L� <br />FORM C (7/811 THIS FORM MUST BE <br />ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FM0035C7 <br />