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0' 0 <br />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 0 '-A W <br />CITY 2j'I_D C L_1i ,, COUNTY _ <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 />A <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 />Ili. OATH I certify that the information provided Is true to the best of my belief and knowledge. <br />Tank Owner/Agent t C-- S-al%oJQ S -T ®Date <br />Print Name -, r G"}{ Phone Roll) C1 J / 6 k;L s - <br />Address ' 7s- S <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY n JURISDICTION FACILITY TANK <br />TANK I.O. <br />`0 RM C (;,9t) THIS FORM MUST BE ACCOMPANiE0 BY PERMIT APPLICATION FORh15 A & 3 UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />