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STATE OF CALIFORNIA <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 <br /> STREET iNg SOu-rk AQGOA/gg:r ?6w -anot eTct.l n l <br /> CITY k0crn U (q COUNTYREC <br /> �9ryJcgnu l <br /> fes ' <br /> II. INSTALLATION (mark all that apply): MAR 3 1992 <br /> ENVIRONMENTAL HEAL-`",,' <br /> PERMIT/SLt%.. <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 /> IV The installation has been inspected and approved by the implementing agency. <br /> dAll 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 i formation pr vided is true to the best of my belief and knowledge. <br /> *Tank Owner/Agent Aj Date 3�2�92 <br /> Print Name <br /> 9AtiIi�Tp�l/ ltT Phone (20�f )fit)! 9653 <br /> Address WET ROAD M60E!�sry , C4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILFACILIIT-Y# TANK# <br /> TANK I.D.# <br /> FORM C(W91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR=5C7 <br />