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STATE OF CALIFORNIA ESQ Es <br /> STATE WATER RESOURCES CONTROL BOARD <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. 1100 <br /> STREET 25-7-75 5045 i N 'P�rr►�¢,so,�l 'R1A� �oAQ <br /> CITY -r P-QC-,-( COUNTY lon ot-j <br /> II. 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 /> [J( The installation has been inspected and approved by the implementing agency. <br /> E:J( All work listed on the manufacturer's installation checklist has been completed. <br /> [�k 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 th ' ormation pr vided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 02/28/92 <br /> Print NamArco r duct Co. - Environmental HealtbPhone ( 310) 407-2605 <br /> Name and I?eLgt_._, Ms . Judy Mason <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 />