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.�• +"i'3 4`�is r�.b « `". �v- #"SbG ,w'i,e.� '`a:ia. r <br /> STATE OF CALIFORNIA a <br /> • .[- �' �, `. - 50V LACES <br /> s - STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W w , <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION as of <br /> FORM C =x C•LIM F <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET /017 VM&Ilfiu' iiy <br /> N <br /> CITY � COUNTS � j2;46? 1^� <br /> II. INSTALLATION (mark all that apply): <br /> f <br /> The installer has been certified by the tank and piping manufacturers. rt <br /> F [ 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 /> ® [ II work listed on the manufacturer's installation checklist has been completed. <br /> The instalt ' n Contractor has been certified or licensed by the Contractors State License Board. <br /> E:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> / rv. <br /> >i r <br /> IIL OATH I cet1i at the inform n provided is true to the best of my belief and knowledge. <br /> Tank Own ` ntf /{ DateEil <br /> Print Name <br /> �4)1%-7- SrAz, -rV o ' lA Phone ( jj a77— . ► <br /> Address E i <br /> ' LOCAL AOENCY USE 0Y <br /> STATE <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> IM <br /> FORM C (7/91) <br /> THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATIQIORMS;A RUNLESS THEY HAVE BEEN irA" D F►REWOIlSLY Foa0035c7 <br /> 9l� :',¢"^nZ�4:.'r�'�, .�r_.a�,°�.;r�,«� _ s � .,�. ,f ,�r�.�k�sn.�_�a .�,-,. rz�aa.• i.-:. . ... w.,,�.`k, �.-.,�.° ., �> r $1`?��" ,_, ,� �x�=,... nom.. �' <br />