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�Ildlrlii�.r <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE f <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a �' <br /> 0 <br /> • � i <br /> SAP 25 f°? I FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM L-:N L-4 <br /> I. SITE LOCATION <br /> STREET 100 `5 1 Cir— �An� <br /> CITY 4-2Al COUNTY –f:4 tJ zT- A4viQ <br /> ll. INSTALLATION (mark all that apply): <br /> lj The installer has been certified by the tank and piping manufacturers. <br /> --The installation has been inspected and certified by a regi4e4ed professional engineer. <br /> [3?--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 /> OeThe installation Contractor has been certified or licensed by the Contractors State License Board. <br /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify thatrmation rovided is true to best of my belief and knowledge. <br /> :�- 1 <br /> Tank Owner/Agent _z) (J(��}�r►��2, r•�,., Date Z/ g <br /> Print Name J��tJ j_ Phone (2-oj )_5&3-3*Z_ <br /> Address sZ.T— !iy• :zw IAO S;r, , (/A '9 3Z3-6 <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 />