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STATE OF CALIFORNIA e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION sr ° <br /> FORM C <br /> COMPLETE A SEPARATE FOR V! FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY ✓�, Al COUNTY SAN i�DAC�U//V <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 /> �C The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> IID Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent �(/T�f/,gjt/p Gp��o� �0�/ Date <br /> Print Name �gjGL `30�E � Gpii/�i/+Z• /1`29NA6EiAz, Phone (51O <br /> Address S�1p 5D/VEpILUr� M 4l�L /477 5p/llxl <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# LE <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />