Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> 1r?0 IN 1 +rlRT � IOR-IJDERGROUND STORAGE TANK INSTALLATION <br /> I,rl'a r •� v r <br /> 1 _ 1flv� <br /> t^ <br /> MAP, 25 PM I '5 <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM Jl` <br /> I. SITE LOCATIONp, <br /> STREET ` 20 <br /> CITY 6-cD/ COUNTY <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-rtefed professional engineer. <br /> ( The installation has been inspected and approved by the implementing agency. <br /> V�AII work listed on the manufacturer's installation checklist has been completed. <br /> �he 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 /> 111. OATH I certify tha information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent �/L /��, Date 3 <br /> Print Name Phone ( Zz)q) —33VZ <br /> Address �ZS"- W , l,E'Q �T N , D �-4 93Z-30 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 111FT1 L111 ❑ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />