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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 LI-2-0 Iskd' sy k SC L"ktigi A <br /> CITY L(D D I COUNTY 3AN SID&RQ A t N <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> Cr The installation has been inspected and certified by a registered professional engineer. <br /> C The installation has been inspected and approved by the implementing agency. <br /> E] All work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> IIL OATH I certify that orma ' n ro i true to the best of my belief and knowledge. <br /> Tank Owner gent Date ZAF <br /> Print Name Phone ( 125 ) 33- S 6 <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D. k m <br /> FORM C (6195) THIS FORM MUST BE ACCOMPIW BY PERMIT APPLICATION FORMS A&B UNLESS THEYYfE BEEN FILED PREVIOUSLY FCig0�5C0 <br />