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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <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 -7-v-�AIe72 e0) <br /> CITY COUNTY A-f <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 /> e installation has been inspected and approved by the implementing agency.All ork listed on the manufacturer's installation checklist has been completed. <br /> All <br /> installation Contractor has been certified or licensed by the Contractors State License Board. <br /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the informatio ovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 'A 7 <br /> Print Name lem U.,&VC-S, Phone <br /> Address 0 4,'---7"&,r x4-e WC14I CP <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FTI I I FT] <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />