Laserfiche WebLink
STATE OFOALIFORNIA <br /> STATE WATER RESOURCES CONTRCL SCARD ., <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> I <br /> STREET � '� �� 1. �7 . <br /> CITY �a _ COUNTY _ ,1.4 t <br /> II, INSTALLATION (mark all tt,at app yy; <br /> The installer has bean certif led by the lank and piping manufacturers, <br /> � i <br /> The installation has been inspected and certified by a registered professional engineer. <br /> The installation has been Inspected and zapprovo by the in�plamentinp agency. <br /> I <br /> All work listed on the manufacturer's fttallallion checklist ilas been completed. <br /> The installation Contractor has been certified or licensed by the Contractors State Ucanse Board, I <br /> iL� Another method was used as allowed by the imp;amanting agency, (Plasse specify.) + <br /> I - <br /> r <br /> 1 <br /> lll.OATH l certify that a irrf matlon p yd Is true to the best of my belief and knowledge. <br /> Tark Cerner an 11Date <br /> Print Nage i}�P� I �— <br /> lone (—� 6 <br /> J <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION n PACIL"# TANK R <br /> TANK f,D.# FT77 ' J <br /> -Or+Aa C(7;9tj TH!8 FORM MUST EE ACCOMPANIED BY PERMIT APPUCRTION FCRW A 4 B UNLESS THEY HAVE BEEN FILED PREVIOUXY <br />