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STATE OF CALIFORNIA say"°Es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3` e01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> E oFORM CA <br /> i <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET t 11E 8VL <br /> CITY COUNTY <br /> II. 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 /> The installation has been inspected and approved y the implementing agency. <br /> 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 /> F-71 Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the informa ' n provided is true to the best of my belief and knowledge. <br /> Tank Own A en Date 141 <br /> Print Name Z, Phone ( )d-7?— 237e <br /> Address ° 1 1!a <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F-7 I f <br /> FORM C(7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAILE BEEN FILED PREVIOUSLY <br />