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' <br /> STATS OF CALIFORNIA gee a <br /> STATE WATER RESOURCES CONTROL BOARD=, <br /> - - CERTIFICATION OF COMPLIANCE <br /> r FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I.SITE LOCATION <br /> STREET ?2'20 Z Vy H W M x=12 I.kl <br /> CITY �'b G o IJ COUNTY C-AW .tStJ 11�J <br /> II. INSTALLATION (mark all that apply): <br /> 01 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 b the it plementing�a�ency. <br /> ,. ,.. _.:,�.__F .,�.,P..: +.a,�..�,,,e.-,�- y.a-+.-Mc'.i.Sk.fwr�k;-x>.,.. :a.,u,w �.:fsYi.�. ..r^hi ,gr•et�<ww-*a,..,..,mer.=,�..•• ...�a.:,.,�.,.-a-.w. ..,-,.�.r.,�=,x.4 .,. �{ <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 /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the i formation rovid is true to the best of my belief and knowledge. <br /> Tank Owner/ 'a Date <br /> Print NamPhone ( 1v) Cd4t LO <br /> Address(/00 Wl I LLI_A64S <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I ILI <br /> FORM c (6195) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY R)ROWSU <br />