Laserfiche WebLink
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 �n^� \' <br />STREETy",z, <br />CITY COUNTY <br />II. INSTALLATION (mark all that apply): <br />The installer has been certified by the tank and piping manufacturers. <br />J20' 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 />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 />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent\i✓y��(��1.�P_tr �p. Date <br />Print Name �,�,L)S�awe, (� Phone ('Tfn <br />Address S -T (, �ry� eC (A + ;-10 <br />LOCAL AGENCY USE ONLY aD V," <br />STATE CCOOUNNTjTYY# JURISDICTION# FACILITY# TANK# Oo-3 <br />TANK I.D. # 'I1 15101,5191-7115 <br />FORM C I7re1l THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROD35C7 <br />0 /-/G-Y8' ori <br />