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. STATE OF CALIFORNIA f sov�s`e s <br /> STATE WATER RESOURCES CONTROL BOARD t,I� <br /> CERTIFICATION OF COMPLIANCE ` <br /> off <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> r <br /> FORM C FED 23 PH is 31 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET _?;1 �2 n M CX—M t\-)' <br /> CITY `:�l FU f-J COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> �JF� The installer has been certified by the tank and piping manufacturers. <br /> t` The installation has been inspected and certified by a registered professional engineer. <br /> [k( 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 /> 0 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 'hest of my belief and knowledge. <br /> Tank Owner/Agent � E,Im � DateD -� <br /> Print Name 71Q t 1 Phone <br /> Address la� � ri oI�(t S }CC /�� � <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> _Z <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c7 <br /> 0 0 <br />