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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD "`i� •••.e <br /> ^P M1 <br /> CERTIFICATION OF COMPLIANCE W �a <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION 11 <br /> STREET Z� l CJl4 tQ�2 Gip /� <br /> CITY CK 1 COUNTY ���� Sflgv/n <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> X 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 Owner/A*nt ul7,Piq Mqp, ilc-1 Date -7//7 A)2— <br /> Print <br /> )ZPrint Name 0d5 Phone (:202) 5g 33 <br /> Address 525 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FCROWSCI <br /> 0 0 <br />