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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 I ZZ:s -1122 s7- /e:2:2a �d <br />CITY /— "of, 4214 COUNTY <br />II. INSTALLATION (mark all that apply): <br />,`The installer has been certified by the tank and piping manufacturers. <br />F --l 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 />54- All work listed on the manufacturer's installation checklist has been completed. <br />E50V ROES <br />P <br />3 0 <br />6 � D <br />• O�CrsOq N�� <br />The installation Contractor has been certified or licensed by the Contractors State License Board. <br />0 Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that the information rovided is true to the best of my belief and knowledge. <br />Tank Owner/Agen Dat_ /f `TT <br />Print Name c Phone y,,Z Zj Z <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <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 FOR0035C7 <br />