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STATE OF CALIFORNIA fso�Pces <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> t <br /> FOR UNDERGROUND STORAGE TANK INSTAATION ! '''� '�r ��-I�1 <br /> LL - <br /> FORM C CL,cr,PN <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 2�3 y 57-0 GING a". <br /> CITY /Of P4 rJ COUNTY r4 n1 <br /> II. INSTALLATION (mark all that apply): <br /> [--] The installer has been certified by the tank and piping manufacturers. <br /> 0 The installation has been inspected and certified by a registered professional engineer. <br /> N/The installation has been inspected and approved by the implementing agency. <br /> FV All work listed on the manufacturer's installation checklist has been completed. <br /> M The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> EJ 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 (?; CIO Dater—/H <br /> Print Name '21 4 L Phone 00 �Qy �53 <br /> Address 1 .17 Q, �l -� " , ! ► 1® ,S`�'() - L� �J�'3� J' <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK-# <br /> TANK I.D.# �Tvl <br /> F©RM C (7/9 1) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY F oassc7 <br /> 0 0 <br />