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• STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION V- <br /> FORM C <br /> MED <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MAR 2 .1 2001 <br /> ENVIRUiVilrti'_,; _ _;H <br /> I. SITE LOCATION PERMIT/SERVICES <br /> STREET 0 LA <br /> CITY STD COUNTY A 0 L� �� <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 /> �j 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 /> *r 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent D C"-4� sa- O,j 5, Date � lA �c—r--_ <br /> Print Name �E� � q �i y— Phone (a.Qj ) Cjs/- �3�5 <br /> Address S7 s 61-A U'` Sal t e L , C 4 <br /> LOCAL AGENCY USE ONLY <br /> STATE �COUNNTTY' J,URISD�ICTIC�N FACILnY: TANK; <br /> TANK I.D. I I I I I <br /> FORM C (7,91) THIS FORA FAUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 3 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />