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• STATE OF CALIFORNIA • e o��=<s <br />STATE WATER RESOURCES CONTROL BOARD ^c" s `'% <br />CERTIFICATION OF COMPLIANCE W ,�'d�: ; �� <br />FOR UNDERGROUND STORAGE TANK INSTALLATION :r rya , <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET <br />CITY Lh. i;LQ Cf COUNTY <br />II. INSTALLATION (mark all that apply): <br />E/ The installer has been certified by the tank and piping manufacturers. <br />D4/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 />EL4- All work listed on the manufacturer's installation checklist has been completed. <br />[L� The installation Contractor has been certified or licensed by the Contractors State License Board. <br />L7 6W Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/AgentP/ ��� Date , LW <br />Print Name,{ cC Phone <br />Address :{n1<�-z SPC 94WO <br />a 01oo?.11-��® <br />LOCAL AGENCY USE ONLY a 0� QQO 141L I ale;. r <br />STATE, COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK LD. # u-'--1-'ts 10 151 Y <br />FORM C (791) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROW5C7 <br />0 <br />