Laserfiche WebLink
M!! CO Et" RESCIUPCE DEPT TO <br /> F� n4113? <br /> w - <br /> STATE WCAUFOP11, <br /> STATE WAtEAAESOURCESOONTgOL 60ARU j <br /> CERTIFICATION OF COMPLIANCE r <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION `g a <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACM TANK SYSTEM <br /> t I. SITE LOCATION <br /> STREET <br /> CITY t f G.v c..1' <br /> -- — COUNTY <br /> II. 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 /> ® The installation has been inspected and approved by the implementing agency. <br /> ® All work listed on the manufacturers installation checklist has been completed. <br /> ® The installation Contractor has been cenilied or licensed by the Contractors State License board. <br /> ❑ Another method was used as allowed by the implementing agency. (Please specify.) <br /> i <br /> III.OATH I oarlity that the information provided is true to the best of my belief and knowledge. o <br /> Tank Owner/Agent � j -- Oate Y-Zq=93 <br /> Print Name I�JA QoI 4 v-NU'0 lJ` -----Phone 03/6") -5_7 Z- 111�S.-- <br /> Address 4061 SES_ O�TL Sfac7o �d.,.Q69� ----- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY 0 JURISDICTION s FACILrTY ar TANK <br /> TANK I.D.s <br /> rpPN C VAI>, TIt$FORM MUST BE ACCOMPANIED BY PERAIrT APPLICATION FORAM A A e UNLESS TTIEY MAVE BECN FILED PREVIOUSLY rOpom+[I <br /> V <br /> 60 39-,d •OOSSC B A-1NCW AbCW EOS9-044-0T6 6DIL0 E66T/6Z/D0 <br />