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. STATE OF CALIFORNIA • sco4�ea <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET � <br /> CITY 1ackforc1 COUNTY Sa0. , )e)Ck qu ),,/ <br /> II. INSTALLATION (mark all that apply): RECEIVE <br /> OCT CT 2 1 1999 <br /> ENVIRONMENTAL HEALTH <br /> ❑k. The installer has been certified by the tank and piping manufacturers. PERMIT/SERVICES <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 /> All 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 the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent C(), Date/eayvdn ra/zrla7 aq y <br /> Print Name JGI m�5_M4 5`e7) Phone (}62) 33 337 <br /> Address Yj� I cl iA4 me�Ay<,c& S w x yl <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# Ll-1=-L=J 0 101116 15 1 1 17h// <br /> 111 46 <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROMSC7 <br /> 0 • <br />