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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION - <br /> 44 <br /> r FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> J <br /> I. SITE LOCATION <br /> STREET <br /> CITY COUNTY �26AClr.-j <br /> II. INSTALLATION (mark all that apply): <br /> V4 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 /> 17-4-1 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 /> LgLl- <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 /> Ill. 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 Nam Phone (15[o) &A4 LQN3qp <br /> Address I ® r f <br /> 614 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# �1FACILITY# TANK# <br /> TANK I.D.# ✓ I1610 <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C8 <br />