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�I STATE OF CALIFORNIA 'i„o„•�y <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 12cAD <br /> CITY COUNTY S4�L ,T�a�ul�1 <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> _ F-1 The installation has been inspected and certified by a registered professional engineer. <br /> [0' The installation has been inspected and approved by the implementing agency. <br /> _ J;�' All work listed on the manufacturer's installation checklist has been completed. <br /> [pr"'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 information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent r/ /�y�-- 066o,-r 14. L�,m� Date '7�j/q& <br /> Print Name�tza�� N(a�re�Lsl� l Phone <br /> Address 113'1 13w0 Iq=TAcaHA, CaA- Q4w54 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# �FAACILITY# TANK# <br /> 7-1TANK I.D.# 1 1 I1 1 1 1 <br /> FORM C p/511 THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&0 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FCRMK7 <br />