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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />CITY &2 0 1 COUNTY <br />11. INSTALLATION (mark all that apply): <br />� � �Gin��rh��������t�a�p����a���. <br />F--1 The installation has been inspected and certified by a registered professional engineer.� <br />>1 The installation has been inspected and approved by the implementingogoncy. <br />All work listed on the manufacturer's installation checklist has been completed. <br />F�] <br />The installation Contractor has been certified or licensed by the Contractors State License Board. <br />L_J <br />Another method was used 8Gallowed bvthe implementing agency. (Please specify.) <br />111911 AIIH:111111111111;1��� <br />Tank 2w <br />0_ �Ag;q7n�tojd Date <br />Print Name Phone (4r1a) 36:Z—? <br />A90& 41 k, wgzni <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION rAcunv# TAwnw <br />IIIT= 1111 <br />TANK |.D.# FT -1 F_][_1 <br />FORM nn/9v THIS FORM MUST 8EACCOMPANIED 8YPERMIT APPLICATION FORM A& BUNLESS THEY HAVE BEEN FILED PREVIOUSLY rORowm, <br />