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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD P< <br /> CERTIFICATION OF COMPLIANCE <br /> w <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> s . <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Ar. 2e::� <br /> STREET <br /> CITY b�1�NT� COUNTY 44c4rA JC;>,Aesku 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 /> FVj 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 the information provided is true the est of ief and knowledge. <br /> Tank Ownz2p 19,90AA-0V�; Date �0��j •q�f <br /> Print Name Oox Phone ( '? SE 7 <br /> Address /O�`i �) �� 44—t .4U rAALA N ► "J4 O <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ 1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />