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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 <br /> CITY �'� C A ' COUNTY ., <br /> 952► 0, <br /> o <br /> II. INSTALLATION (mark all that apply): AUG , t <br /> 2The installer has been certified by the tank and piping manufacturers. ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> ❑ The installation has been inspected and certified by a registered professional engineer. <br /> : he installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> �j The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> ❑ Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the7!;tz <br /> rue to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name Phone ( ? 4) `�77Zc�S�g! <br /> AddressC,4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK R <br /> ` 1 / EJB <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR009SC7 <br />