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STATE OF CALIFORNIA soy °Es <br /> STATE WATER RESOURCES CONTROL BOARD �P .°"'"" <br /> CERTIFICATION OF COMPLIANCE ° <br /> � r <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET —7� <br /> CITY S+ac-L-6-1 COUN -J <br /> II. INSTALLATION (mark all that apply): <br /> X 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 the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date tp a� -CIS <br /> Print Name �"1� 1"[��l��f S�� Phone (S,io <br /> Address ?fo®1—� �•� ,:_ �`�"' L%,jPrN,dvre c-A gys.sa <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# (L-' <br /> µ <br /> TANK I.D.# al <br /> [ 7 �� J <br /> FORM C (7/91) THIS FORM MUST[BE ACCOMPANIED BY PERMIT APPLICATION FORM9a&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />