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SrATE OF CALROMA <br /> STATE WATER RESOURCES COWROL BOARD <br /> CERTIFICAMN OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1.SITE LOCATION <br /> STREET <br /> ary COUNTY <br /> 11. INSTALLATION(mark all that apply): <br /> The installer has been cariffied by the to and piping manufacturers, <br /> Vinstaliationhas been inspected and certified by a registered professional engineer, <br /> T,he installation his been inspected and approved by the Unplernenting agenoy. <br /> I work listed an the manufacturer's installation checklist has been completed, <br /> The installation Contractor bas been certified or licensed by the Contractors to Licenw Board. <br /> Another method was used as allowed e implementing agency. (Please specify,) <br /> Ill.OATH I certify that the inforniqUon provided is true lo the best of my belief and knowledge. <br /> Ta e nate <br /> Prird NamedPhone (�W)dW- <br /> j A.I A --Al <br /> Address <fA 21-3-76?VZ <br /> LOCAL AGENCY USE ONLY <br /> STATEOMNTY# JURISDICTIONs FACII-irys TANK a <br /> r---T---1 -E = <br /> TANK I.D.# = T <br /> E EE L <br /> FORM 0(W1} THIS FORM M T BE ACCOMPANIED BY PERMrr APPLftTION FOR NS A&9 UNLESS THEY KAYE BEEN FILED PREVIOUSLY <br /> L 'd 9010LL;!;60Z dVJ-S1S3M/dVJ-S-1-1V HOd--] HV95:6 966L—OL-6 <br />