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STATE OF CALIFORNIA f5 Es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE t <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s o' <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. Cc IOU <br /> STREET z S-7 7S �S o oi H -i--,rj-T-rt=2 c!:,,-1. p>A <br /> CITY COUNTY of-zo- I. <br /> Il. INSTALLATION (mark all that apply): <br /> X 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 /> X The installation has been inspected and approved by the implementing agency. <br /> X 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 /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the ormation =videdisthe best of my belief and knowledge. <br /> Tank Owner/Agent Date 02/28/92 <br /> Arco 16rductgCo. — Environmental Health ( 310 407-2605 <br /> Print Name an_ S ety De-pt. me, uJ dY� MMason 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 FOR0055C7 <br />