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STATE OF CALIFORNIA '.+ •... <br /> STATE WATER RESOURCES CONTROL BOARS .� <br /> CERTIFICATION OF COMPLIANCE ' ` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> i <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM (979 <br /> l <br /> I.SITE LOCATION <br /> STREET •/ 4'0-Z W • NA-M MOZ LN 1 <br /> S v K o �o U IN <br /> CITY � G � � COUNTY ��'"�! �► <br /> II. INSTALLATION (mark all that apply): <br /> b <br /> 3i <br /> l <br /> The installer has been certified by the tank and piping manufacturers. <br /> ( <br /> Ci The installation has been inspected and certified by a registered professional engineer. AI <br /> ' The installat h as:-been inspected and.approued bathe implementing,,agency.., <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> �T The installation Contractor has been certified and licensed by the Contractors Mate License Board. A <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> �i <br /> Ill. OATH I certify that the formatiogrovi is true to the best of my belief and knowledge. <br /> Tank Own it Date <br /> Print Name LVM r ArpI 50 ft�PM I CAL Phone (5 10 )lOI`T lJ�1U <br /> L6* <br /> Address POO KfI�L 1,445 ';-T� L6*til 614*77 ' <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANKANK# <br /> TANK I.D.# L�� PEI) <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOP= <br /> j <br />