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• STATE OF CALIFORNIA • pEyoo,o.yc <br /> STATE WATER RESOURCES CONTROL BOARD p a, <br /> CERTIFICATION OF COMPLIANCE a <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> rST MA-10 Sf <br /> CITY 12IPorJ COUNTY SArn1 JOA! cOI i <br /> ll. INSTALLATION (mark all that apply): <br /> dThe installer has been certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer. <br /> Q�The installation has been inspected and approved by the implementing agency. <br /> [R"AII work listed on the manufacturer's installation checklist has been completed. <br /> X 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/Agent f yynp ��j�E�/��� Date J2//Ijr <br /> Print Name R3 GRRREfT - 411nl PERM►TS DESK Phone (S/O ) 992-9.5ab <br /> Address 4P.0, IBOx soo4 <br /> 50A R 0-014) 0)45$3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I,I).# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR7=7 <br />