Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ^� •+ ��� <br /> CERTIFICATION OF COMPLIANCE o <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONw X- <br /> a <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 39 k) Q C<-M.x,.►' ^� <br /> CITY r COUNTY V r1 <br /> II. INSTALLATION (mark all that apply): <br /> F The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> 01", 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 /> ]V� The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> L:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the 'nformation pr vided is true to the best of my belief and knowledge. <br /> Tank Owner/A ent i <br /> Date <br /> Print Name <br /> -I Q)4 L Phone Q0� ) <br /> Address 77 <br /> I - <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# EI17= Z o �P <br /> 2`�7�� <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003507 <br />