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STATE OF CALIFORNIA E50VACES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION v° <br /> FORM C <br /> C�C.FOP N.F. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Q-U l 16— 5-5o P 17-1- <br /> STREET SoS N. MA-110 5ZR4FFr <br /> CITY MAV76-6A COUNTY 2`2`J �o�4c-.v( <br /> II. INSTALLATION (mark all that apply): <br /> dThe installer has been certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified by a registered professional engineer. <br /> [Y� The installation has been inspected and approved by the implementing agency. <br /> EY( All work listed on the manufacturer's installation checklist has been completed. <br /> [� The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name Phone ( ) <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ ❑_❑ <br /> FORM C (M) THIS FORM MUST BE ACCOMWD BY PERMIT APPLICATION FORMS A&B UNLESS THE6E BEEN FILED PREVIOUSLY <br />