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`/ STATE OF CALIFORNIA -ftI <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <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 /> CITY COUNTY ✓fes✓ TOq c�ui�/ <br /> It. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> O 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 /> L] Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information pro ided is true to a best of my belief and knowledge. <br /> Tank Owner/Agent Date —Qlp— <br /> Print Name 40 Phone W 7� ! �Z ZX <br /> Address smPAY lL, vj—c?e <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# _ ff TANK# <br /> TANK LD.# M �i <br /> FORM c (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FCRM35C7 <br /> 1 <br />