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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOA pEg°�"ms's <br /> CERTIFICATION OF COMPLIANCE 3 ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION as <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET ' -71 ► A4 1--►`. <br /> CITY S COUNTY - �� v►'► <br /> II. 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 /> All work listed on the manufacturer's installation checklist has been completed. <br /> J <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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/lax �� ��� � � Date j_ 2 4..- Q Lv <br /> Print Name L-dL-f .+..4.o )) Phone (ri)b ) 4,35-2,1-1 y y <br /> Address 2 lS 1(0 SJnr' 6�v�� «��-c� (�� a, G/� g s—z J-g <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ E I I I I <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />