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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 19 <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 Af—Go <br /> STREET <br /> CITY <br /> TrG!�� COUNTY 4Ca k� Ve d`G2 U 1 <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 /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that t e i formatio pr vided is true to the best of my belief and knowledge. <br /> Tank Own ge Date �p- •�� <br /> Print Name Voi4aw U, OF ErfT1WC-,Phone (10) SS <br /> Address 40747 a�Ielgl,a 4-1-L. �5u 5TC �� g C"k-51 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />