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STATE OF CALIFORNIA ofsoo <br /> STATE WATER RESOURCES CONTROL BOARD �¢ <br /> 4 <br /> CERTIFICATION OF COMPLIANCE <br /> �a <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET Z ® <br /> CITY M ANTE-C-A COUNTY !N N c9 IL)t 1� <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> [r�The installation has been inspected and certified by a registered professional engineer. <br /> e installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> t� he 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/AgentDate <br /> Print Name 2)W R-2z Dy^ /2 OZ dJ Th- Phone ( 201j 2 3q-Lll q I <br /> Address //3 Z /V. k79�j on/ m4lvagA CA- X7533 d <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM c (7igi) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />