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STATE OF CALIFORNIA PE SO�w S C <br /> STATE WATER RESOURCES CONTkOL BOARD e. . <br /> CERTIFICATION OF COMPLIANCE T a <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> s ; <br /> r <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. �-n100 <br /> STREET ?�1-7-75 Sov7yA -P 7-1 rz otil <br /> CITY COUNTY 0S a01 <br /> II. INSTALLATION (mark all that apply): <br /> E�j The installer has been certified by the tank and piping manufacturers. <br /> 0 The installation has been inspected and certified by a registered professional engineer. <br /> E:j The installation has been inspected and approved by the implementing agency. <br /> Ej All work listed on the manufacturer's installation checklist has been completed. <br /> L_j 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 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 <br /> Arco r duct Co. - Environmental HealthPhone ( 310) 407-2605 <br /> and—S e-ty Dept--,--Ms--Jud- 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 oaco sc <br />