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• STATE OF CALIFORNIA 40 <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />(ED <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET MEL' \-VVI— SC � <br />CITY �+y COUNTY _�J1 <br />II. INSTALLATION (mark all that apply): <br />[0 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 />[Vr The installation has been inspected and approved by the implementing agency. <br />[]v' All work listed on the manufacturer's installation checklist has been completed. <br />[v]/ The installation Contractor has been certified or licensed by the Contractors State License Board. <br />❑ Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent \,R K%n-P, L7 Cn) Date 7k\113 <br />Print Name ( %s M� Phone (` )p) 2, � <br />Address � 10 t' Al x4 o-ri </--ij <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ I I 1 11 <br />P-UHM t, (nai) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />