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STATE OF CALIFORNIA Pfso .ESS <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE w� : <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. CotOO <br /> STREET 25 -7i -�Lo I� "r , TF(Z.,-,h til -, ::�.' tlZ- n ra C-) <br /> CITY -T COUNTY F �1 -10E1,Uiti, <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 /> Lj 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.jPlease 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 A Date 02/28/92 <br /> Arco oduct Co. — Environmental Health d <br /> Print Name and JudyMason Phone ( 31 407-2605 <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 />