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STATE OF CALIFORNIA fgOV ACE3 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 9 <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 /> P� w <br /> STREET 2 21 C 1 li <br /> CITY S fo G /1:to- COUNTY -5c? Yi cid a 0 j) <br /> II. INSTALLATION (mark all that apply): <br /> F--] The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> X The installation has been inspected and approved by the implementing agency. <br /> 0 All work listed on the manufacturer's installation checklist has been completed. <br /> X The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the informatioq provided is r e to the best of my belief and knowledge. <br /> 9 <br /> Tank Owner/Agent Date 7- <br /> Print Name '�'�y9 ?; Dj��,Arl� Phone (?,,-7 D3�S <br /> Addressr y.4�Tr��2 WA <br /> LOCAL AGENCY USE ONLY <br /> STATE COUmNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# d_�17 I <br /> 111M Fill I L:?l <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />