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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 9, <br /> I. SITE LOCATION <br /> yC-74 <br /> STREET 1-3 <br /> J <br /> CITY C��'Z` (' COUNTY �-'1'> <br /> II. INSTALLATION (mark all that apply): <br /> Z7e installer has been certified by the tank and piping manufacturers. <br /> 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 /> work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the in t' n r ided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date (( j^ <br /> Print Name 72 " J"I"' Phone �7 <br /> Address u. c) 7 1TWL4f Z Z <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D. # <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035CS <br />