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STATE OF CALIFORNIA <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 l z- � 0 0 HiWLf-W K06j.=b <br /> CITY L8r ffiZ0f COUNTY abA Q-9 fAJ <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 0 The installation has been inspected and certified by a registered professional engineer. <br /> XThe installation has been inspected and approved by the implementing agency. <br /> X' 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date Z— 0 0 <br /> Print Name ' Phone <br /> Address (1,0 SC-,Al) yt(fA r! e <br /> LOCAL AGENCY USE ONLY 1/� <br /> COUNTY# JURIMCTION# FACILITY# TANK# c <br /> STATE ������ �61 �,/ <br /> TANK I.D.# .1 1__�J 6 _._ 5 rCl� <br /> FORM c (T91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&6 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FpRaoasC7 <br />