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v <br /> STATE OF CALIFORMA <br /> - s , STATE WATER RESOURCES CONTROL BOARDv <br /> CERTIFICATION OF COMPLIANCE <br /> "E FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> t Z9 11: 02 <br /> FORM C „o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET -35 IR C--- y4pUne� [� <br /> CITY& & COUNTY 6�0 J 6 U li? <br /> II. INSTALLATION (mark all that apply): <br /> [)j 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 /> 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 /> Ill. OATH I certify that the information provided is true to the b st of my belief and knowledge. <br /> 9 oJ146t. jjl)ZU000 �dar, <br /> Tank Owner. ent / Date /0Q qS <br /> Print Name 0j 1s of LQ > uC r n Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# M <br /> FORM C prod THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 8 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FMOMK7 <br />