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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION e <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET WV0 WES% 44AI,6 <br /> CITY ..s�GK i a� COUNTY SAnZ Z A lli t/ <br /> II. 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 /> 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 7/+C//C Date 5- 41-M <br /> Print Name M/c s � E �r� /�E, Phone (spy )�_ ,7 /7 <br /> Address d,5'0 'O Si. �RESi�a CA, g37G0 —Dad/ <br /> r <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR09]5C] <br /> 0 0 <br />