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STATE OF CALIFORNIA fse� °Es <br /> STATE WATER RESOURCES CONTROL BOARD P ' <br /> CERTIFICATION OF COMPLIANCE t <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. Cnlo0 <br /> STREET 2S-7-7L t---)L57 H -P iz-rm!cL-,o rl ter�' �•�o�=�s <br /> CITY -T1<t::4c,r COUNTY 5QT-' JCAo.� <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 /> [j 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 Name Arco oduct Co. - Environmental Healthone <br /> _and_ Qty DQ_P_t_—, Ms_ Judy Mason 310) 407-2605 <br /> Address 17315 Studebaker Rd. Cerritos,_ _ CA _ 9.0701 <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&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY Feaco�sc� <br />