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i <br /> FTAT2 OF CAWFOAN!A <br /> STATE WATER RESOURCES CON'TkOL BOARD ,�`"" <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> i <br /> I. SITE LOCATION -4y4Ger� 44� &VOZ. O <br /> I _ <br /> I OirY COUNTY 4A kJ &A..z3:?, u i <br /> 11. INSTALLATION (mark a! tna+apply): <br /> I <br /> I <br /> The installor has bean Certifled by the tank and piping manufacturers. <br /> !1 a installation has been inspected and cen lied by a registered professional enginear, l <br /> The Instailatlon has been inspected and appravad by the Implementing agency, <br /> AJ work IlSted art the manufacturer°s instWiati4n checklist has been completed. <br /> The installation Orltractor has been certified or licensed by the Contractors State License Board. <br /> L�' Anothar meti-iod was used as aJ;pwed by tre implementing agency. (please specify.) <br /> I <br /> I <br /> I <br /> Ili. OATH I certify that t e i formatio, p vided is true to the best of my Belief and knowledge. <br /> j lank Own go sate <br /> _— <br /> Print Mame <br /> 2sIP C-,Pnoo e (q-'*) 5"s I. ?TS_r_ <br /> Address `�_��_. t+l 7�- #��_.�.��'11�. ��.s�•�/..s +:' <br /> I 4 <br /> i <br /> I <br /> LOCAL,RCENCY USE ONLY <br /> STATE COUNTY a JURISU:CTiON a FACII 11 Y t TAN, �t <br /> TANK 1.D. <br /> ;NM C(7,'aj) THi2 FORM MUST SE ACCLIMPAKED EY PERMIT APPLICATION FOFINS A&8 UNLESS THEY HAVE$FEN FLED PRBVIpUSLY FORxyec� <br />