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• STATE OF CALIFORNIA • Eeoo.�es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION er ° <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET���34 QST MAItJ ST' <br /> , _ <br /> CITY _L ?b0 COUNTY S" <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 /> dThe installation has been inspected and approved by the implementing agency. <br /> dAll work listed on the manufacturer's installation checklist has been completed. <br /> [7f 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 theinfo tion provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Rr B. GAWM-194,5✓ROA1 Date 12 14195- <br /> Print Name ++774 fERM175 DE99 Phone ( )o ) 642-0)S00 <br /> Address P4 0,SOX 520 4 <br /> SAW RRmo�l c i> 9458 3 <br /> LOCAL AGENCY USE ONLY <br /> STATE rCOUN��TY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# W <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br />