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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />50�A�E5 <br />I. SITE LOCATION <br />STREET <br />CITY Joc�'''� COUNTY �/i✓� �o¢Q�i'✓► <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 registered professional engineer. <br />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 />[ The installation Contractor has been certified or licensed by the Contractors State License Board. <br />EX Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Ow NA e ���5 Date y --//-p / <br />Print Name �� Phone �-sy ) yyy_�y3O <br />Address S':R 7 Al P4r <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # <br />F0RM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003507 <br />