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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 0 <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONrs os <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 33.55 rAIT <br /> CITY CA COUNTYZ> I-J <br /> -�;i <br /> Il. INSTALLATION (mark all that apply): <br /> ❑ The installer has been certified by the tank and piping manufacturers. <br /> F--1 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 /> ❑ 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 /> 6C F'f <--H6VRdPN AF1M -THSTALL-,M1=" <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date i(- <br /> Print <br /> I-Print Name CHC-%/9Z>4 M=JC:--rS Cc>, Phone M-5 -9>IZ- <br /> Address �o. <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILFFY# TANK# <br /> FT-] FT-F-1 <br /> TANK I.D.# <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />