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STATE OF CALIFORNIA E9 "SEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> HEA f0UNDERGROUND STORAGE TANK INSTALLATION as . <br /> f FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET !a C) <br /> CITY LC3-D I COUNTY J-DAi!,AJ <br /> II. INSTALLATION (mark all that apply): <br /> [E-'--The installer has been certified by the tank and piping manufacturers. <br /> EK The installation has been inspected and certified by azogi&tered-professional engineer. <br /> [Q/-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 /> �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 /> III. OATH I certify at the info ati provi ed is true to the best of my belief and knowledge. <br /> Tank Owner/Agent (JL w(, Date Z/Al <br /> Print NameRli4 Phone �4TIf <br /> Address 6'77!�— Z <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 FOR0095C7 <br />