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• STATE OF CALIFORNIA • <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET 101 ( o I l nt- ST 7,z I -�,ql <br />CITY COUNTY .� ' s LJ 1 rJ <br />II. INSTALLATION (mark all that apply): <br />The installer has been certified by the tank and piping manufacturers. <br />r�71 The installation has been inspected and certified by a registered professional engineer. <br />Q' The installation has been inspected and approved by the implementing agency. <br />© All work listed on the manufacturer's installation checklist has been completed. <br />Cij The installation Contractor has been certified or licensed by the Contractors State License Board. <br />El Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent �,f � � �,► j C9,V,)Q CQ Date 1 �l <br />Print Name M) _ Phone -A� is <br />Address '!"0 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # <br />1-1 � V-1 i nis rUKM onus I tit AUUUMPANItU tir FLKMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />