Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 32�22-- k , M 64 LN - <br /> CITY COUNTY apw A0 <br /> 11. INSTALLATION (mark all that apply): <br /> A- The installer has been certified by the tank and piping manufacturers. <br /> r <br /> El The installation has been inspected and certified by a registered professional engineer. <br /> 9" 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 /> Ill. OATH I certify that the ' formation rovi is true to the best of my belief and knowledge. <br /> Tank Owner Datew <br /> Print Nam Mee <br /> , 4, Phone <br /> Address-Z10,9f, 4r- ii 5alw LEW4191120 145211 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# L�91 � IL131 <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOPM35C8 <br />