Laserfiche WebLink
STATE OFCAUFORNIA ^ .� <br /> STATE WATER RESOURCES CONTROL BOARD :` c <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> Fl. ITE LOCATION <br /> STREET Z' c PtaNr H P�+n <br /> CITY COUNTY -5,41 T'Q 1 J <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 /> d The installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> Qo,The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> L�] Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent � C/�yy� 0:,ps�N, Date 71114(1 <br /> Print Name 040 r <br /> ;G '.(���Q( Phone <br /> Address 1131 1 NL y a�� Mt-Vn .1 jq!:Ta,_UHA, C.A- QS/w54 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D,# <br /> FORM C I7191l THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORM5V <br />