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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD ...... <br />CERTIFICATION OF COMPLIANCE 01 <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />R� v, <br />FORM C <br />DFC 2 2 1992 <br />CAVIROW,4ENT4L HEALT�i <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM prR <br />M, <br />STREET 19&!2 tAKI.-T 11-1� SK <br />C I T Y ff&--1 COUNTY 51W JVN%))r4 <br />11. 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 />V The installation has been inspected and approved by the implementing agency. <br />0' 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 />0 Another method was used as allowed by the implementing agency. (Please specify.) <br />11111 111111111 11111111 F I I I <br />• <br />• <br />Tank Owner/Agent&W5111&�-131Jt9- &139Uc15 W. Date gl&2— <br />-® <br />Print Name. '4 01 T u <br />EM l� Phone <br />Address to 0,97,I)t& Aono-x,/ i�� <br />�41— q41–Z-3 <br />I X41C I ule] 4 <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # � FTF I I I I I I 11 I <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />