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STATE OF CALIFORNIA fso�A es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> CN'v'1R0N';-4ENTA! :' - <br /> PFRfl4lT �6,� t, �14DERGROUND STORAGE TANK INSTALLATION <br /> tt���L <br /> FORM C <br /> 94 MAR 2S P9 I: 38 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM UPL_ <br /> I. SITE LOCATION <br /> STREET `�O� S C lA ca <br /> CITY Ly COUNTY sf\tj zt:),A q"i ► rV <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> Yj The installation has been inspected and certified by a professional engineer. <br /> The installation has been inspected and approved by the implementing agency. <br /> [P----All work listed on the manufacturer's installation checklist has been completed. <br /> [k---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 /> 111. OATH I certify th the infor tion Ovide is true to best of my belief and knowledge. <br /> Tank Owner/Agent CjL77�9 i►►.��C /,� Date :. �u <br /> Print Name �� Phone (2zq ) X33 33S�L <br /> Address .SZr Gam / Ste, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# LE F= <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />