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STATE OF CALIFORNIA SoUA es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCEo <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 417 S. 4g,' 67, <br /> CITY /�/Artl?`L-Cr'1 COUNTY ,4A) �oAQQ l <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> 0 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 /> D 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 Owner/Agent S, C, w,,,,� D Bgjz It bate 111,61% <br /> Print Name DaL Bvvxft Phone (209 ) S4S -I►LL <br /> Address P. O . pix 109 9 50 -1,, C 1� . 9S 31 1�- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURI��SDICTIIO�ON# FACILITY# TANK# <br /> TANK I.D.# FF EEF <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />