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STATE OF CALIFORNIA eo "OEs <br /> STATE WATER RESOURCES CONTROL BOA "E ^ <br /> CERTIFICATION OF COMPLIANCE 3 ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION o' <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 2�o I L.r-� <br /> CITY COUNTY --� <br /> Il. INSTALLATION (mark all that apply): <br /> 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 /> The installation has been inspected and approved by the implementing agency. <br /> II completed. <br /> awork listed on the manufacturer's installation checklist has been com� P <br /> 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner GA �-�. Date t -2 �� <br /> Print Name j_0i� ))� � Phone (9 16 )2,,3 jS-2 ,-t <br /> Address 2k BU Sv�"j e- (_2 1✓�, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ FFI <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />