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STATE OF CALIFORNIA ESo "'cs <br /> STATE WATER RESOURCES CONTROL BOARD P <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 f <br /> STREET a M ARoj,�Asb <br /> CITY I P COUNTY � -TC Ab U II N <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 manufacturer's installation checklist has been completed. <br /> xThe installation Contractor has been certified or licensed by the Contractors State License Board. <br /> LJ Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information rovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date V ` <br /> Print Name OOT Phone �'09) g924)3 <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7r91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY T FOR005C7 <br />