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STATE OF CALIFORNIA ",.Ace. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION 4 <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET --?� 02, Iki - HA-+A MjE�g L&I <br /> CITY :��' -To6 1�-To N COUNTY JoAAL] I tJ <br /> 11. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> I 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 and licensed by the Contractors State License Board. <br /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> .L <br /> Ill. OATH I certify that the * formation rovid is true to the best of my belief and knowledge. <br /> Tank Own,!�p qT IF Date <br /> Print Namcf <br /> ,,/HM I CAL Phone (5U)) <br /> Address k? 101 Ll I-MA '�T- 5M LGqJPZO !94,9-77 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK <br /> TANK I.D.# 124 15 1 I 1 Z!j I ® <3- <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORMCS <br />