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STATE OF CALIFORNIA 0 <br /> STATE WATER RESOURCES CONTROL BOARD "s <br /> CERTIFICATION OF COMPLIANCE W01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 2-4Z-o <br /> &I r A-e— <br /> CITY 10A COUNTY <br /> 11. 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 /> 4�41he 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 informa i n provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name Phone gvq )30-1:�Pro <br /> .-Address A& so' U, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 11IFT-1 [:]- Ill = <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />