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• STATE OF CALIFORNIA soa,�es <br /> STATE WATER RESOURCES CONTROL BOARD • v PF `% <br /> CERTIFICATION OF COMPLIANCE ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION sf <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION / <br /> STREET 410yo lNESi �f+ �/� I DiES�c T7�z/e � <br /> CITY COUNTY <br /> ll. INSTALLATION (mark all that apply): <br /> 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 /> 0' The installation has been inspected and approved by the implementing agency. <br /> d All work listed on the manufacturer's installation checklist has been completed. <br /> er,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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/AgentDate ; V--e,;,2- <br /> Print <br /> —qZPrint Name /Vj��yL ,16,E Phone (2p9) 2G3_52/ 7 <br /> Address 66d O .ST. Z�d 41-11 . 93760 —DOO <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# STANK#��� <br /> TANK I.D.# 31 FTT� © I I 1 1 1116 1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />