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z F <br /> STATEOFCAUFORNIA �{ <br /> I STATE WATER RESOURCES CONTROL BOARD ' <br /> � yam..• <br /> CERTIFICATION OF COMPLIANCE- y <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION x- '• <br /> 1 i <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 4 <br /> 1. SITE LOCATION ' <br /> STREET ZI=X-3 c• r ii — '{ <br /> i.., <br /> CITY t d COUNTY <br /> ilEkL- II. INSTALLATION (mark all that apply): 6 <br /> [?The installer has been certified by the tank and piping manufacturers. <br /> L. <br /> j ❑ 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 /> i. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> I� �4 <br /> 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 /> I <br /> i <br /> III. OATH I certify that the information provided.is true to the best of�m belief. Y p l y be a and knowledge. <br /> Tank Owner/Agent ;, LDate 7 cr(y <br /> Print Name ZFl~t � Phone (�!oC <br /> Address 1 131 l..t. M L Qc� 4 I��yL7 f�iZM C UM,4 ';171-v-54 <br /> T_ sem- <br /> ;i <br /> LOCAL AGENCY USE ONLY <br /> I Is <br />,. STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> L <br /> TANK LD.# ❑ <br /> FORM C (719!) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c7 <br />