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STATE OF CALIFORNIA ESpVecEa <br /> STATE WATER RESOURCES CONTROL BOARD APP <br /> CERTIFICATION OF COMPLIANCE W�„ ;�01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET S CoJr- C—,t0 <br /> CITY A-0c-m'0,J COUNTY <br /> ll. 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 tha information provided is true to the best of my belief and knowledge. <br /> Tank Owner/AgentP;49�" Date \U -an-qj^ <br /> Print Name �„� 2�CXe_f S o s.1 Phone (�rg ) �{y1 -ayg <br /> Address Sraj 2CC.�R,�� e c'}— Lig cr-"-d1-e L:A 114 S� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# v Cj J <br /> TANK I.D.# !/I 51 / ICS 717 1 � b <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 10 <br />