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4FSTATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD le <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 110---�s S VAtv-\ S i <br />CITY V\AAyr'(1e-C-A- COUNTY ;,,A 4 Ak I <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 by the implementing agency. <br />All work listed on the manufacturer's installation checklist has been completed. <br />X 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 />111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent Lke v ftp --- k t- ,, <br />Print Name <br />� �j Date Z j,� -,,6 .- 9-3 <br />arstV Phone (j/()) ffYZ-7jSO <br />Address ,may 16 C rbc; Sr.v��l�o,yy.o� <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ 177� 2 S <br />FUHM c (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />