Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD, <br /> CERTIFICATION OF COMPLIANCE 3-_ <br /> FOR UNDERGROUND STORAGE WANK INSTALLATION ' <br /> FORM C <br /> { COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 05A) a <br /> a <br /> 9 <br /> 1. SITE LOCATION <br /> STREET �Zl'2► IA/ _ PAId M ETZ t N <br /> CITY 9TO61el oto COUNTY JOA&V 1 W <br /> 11. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> C The installation has been inspected and certified by a registered professional engineer. <br /> The inst�llapo has:been inspected alad,aPProygd by�the,in <br /> qplemenong 49pncyR i <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 /> s <br /> 111. OATH I certify that the formation rovi is true to the best of my belief and knowledge. <br /> Tank Ovvneegpw Date <br /> Print Nam m M I CA4, Phone (G�0)G44+ <br /> ,AddressS &2 O&2 W 11.L I AM6 !r.I �'"�• -14 i �7 <br /> LOCAL AGENCYUSE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I 2 <br /> FORM C IWO) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY `- MFMSCe <br />