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STATE OF CALIFORNIA S eeuv"=ee <br /> STATE WATER RESOURCES CONTROL BOARD ^"" +, <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 <br /> CITY GeZ�,✓ COUNTY ��F//✓ �l�/� <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 /> ��TThe installation has been inspected and approved by the implementing agency. <br /> V <br /> l work listed on the manufacturer's installation checklist has been completed. <br /> he installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify th e I olna 'o rovid Is rue to a est of my belief and knowledge. <br /> Tank Owner/Agent .✓�AFt� �U/C� Date 't—► L4 <br /> Print Name �^ A)L TL2F7 Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br /> 0 0 <br />