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STATE OF CALIFORNIA zo "Os <br /> STATE WATER RESOURCES CONTROL BOARD PPE o°ti <br /> 9 <br /> CERTIFICATION OF COMPL:•ANCE t <br /> y � It <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION �- <br /> FORM C C C,fppN' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM n <br /> 11RCo �AC* 1313 <br /> I. SITE LOCATION <br /> STREET \CSb C� • �A�N S"�. <br /> CITY OVA eC-G COUNTY Z&--r` �3'jACQ v <br /> II. INSTALLATION (mark all that apply): <br /> n 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 /> The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> Il Another method was used as allowed by the implementing agency. (Please specify.) <br /> c --CgNus e <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date N\120ci-I <br /> Print Name _u) \\�� 1`�\- 2f� �-p+ - Phone (-11y ) bio-s46 q <br /> Address C.p '�,d -%4 COO-3% AR7e,s,c,4 (-& ci0102. -to 6.3$ <br /> LOCAL AGENCY USE ONLY <br /> STATE COUmNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIFO BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />