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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION rW „ <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET q31 � t C C l `� \ <br /> CITY `--ted i COUNTY SOP-IIAc74b <br /> II. INSTALLATION (mark all that apply): <br /> 7t 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 /> xThe 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 /> J Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the ' formation provided is true to the best of my belief and knowledge. <br /> Tank Own gen) p '{ r,�2 ` ae,� Date ( ( q $ <br /> Print Name Phone QS-6O) `bz$ <br /> Address (o% IA� A Vk,, <br /> LOCAL AGENCY USE ONLY <br /> STATE CO�UNTYY# JURISDICTION# FACILITY# TANK# <br /> I <br /> TANK I.D.# F LT[= <br /> FORM C prem THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FCRX35C7 <br />