Laserfiche WebLink
STATE OF CALIFORNIA 0 e o°W=ea <br /> STATE WATER RESOURCES CONTROL BOARD .° s =O�� <br /> CERTIFICATION OF COMPLIANCE W , <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION 9s . o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 31 Q O <br /> CITY COUNTY 1. 4!20/6-2 <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> F7 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 /> ED Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the informati n\+provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 1 Date /0/,?/ 3 <br /> Print Name ,g / Phone (ZO )) 3 <br /> Address 4--ft E mayi r kxvl e"fl / 6�202 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# r—T-1 = I I IID <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0005C7 <br /> 6 0 <br />