Laserfiche WebLink
STATE OF CALIFORNIA , ESoyA es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W� s <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> h SITE LOCATION <br /> STREETS/ / laaari � <br /> a <br /> CITY COUNTY —'Z�� (k942&61-1 <br /> 11. INSTALLATION (mark all that apply): <br /> D 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 /> 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank ©wner/Agent s 9 Date <br /> Print Name -- -Ili'' _1_�1L-L11,if Phone <br /> Address *4931)'-3: -- <br /> b M a �, 'SaCP_AIM(-- )10 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURWICTION# FACILITY 4# TANK# <br /> TANK I.D.# FT-1 ED I <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A$8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR00350 <br />