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STATE OF CALIFORNIA Sc Es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W � <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s �r <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Al2Z-.d -4 60 ZC:) <br /> STREET � � ���� (bl✓- 1 I rJ� b <br /> CITYTIS, COUNTY �C' amu f <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> KThe 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 /> III. OATH I certify that a info mation p v' d is true to the best of my belief and knowledge. <br /> Tank Owner gen Date �p <br /> Print Name14rcp C6 Q&one <br /> -Address-- &7 -- , C� �� L1I 6A <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 FOR0095C7 <br />