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STATE OF CALIFORNIA <br /> pE SOU n.eEs c <br /> STATE WATER RESOURCES CONTROL BOARD °tib <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. X100 <br /> STREET ;Sou-n4 -PA-cgs 'ROAD <br /> CITY --rRAc.%-e COUNTY 5pv.1 log ab i a <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 /> 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 /> ❑ Another method was used as allowed by the implementing agency.•(Please specify.) <br /> Ill. OATH I certify that th ormation p vided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 1 Date 02/28/92 <br /> Arco r duct Co. - Environmental Health <br /> Print Name ( 310) 407-2605 <br /> and S__ eta D !pt--,---Ms. Judy Mason Phone <br /> Address 17315 Studebaker Rd. Cerritos, CA 90701 <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 FOR0035C7 <br />