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STATE OF CALIFORNIA ^mss <br /> STATE WATER RESOURCES CONTROL BOARD PESOV ^'� <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION >� fir: . <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET /950 A6 �i✓'f"L <br /> CITY —22551 '`✓ COUNTY ��✓ Amu. ✓ <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 /> �j The installation has been inspected and approved by the implementing agency. <br /> D;2T 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 /> E1:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information ovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date jam_D6 —gS <br /> Print Name /� /� S Phone 94-2 2L(S <br /> Address Ne-.P- , Cu S 20 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F <br /> FORM C prep THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORMK7 <br />