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• STATE OF CALIFORNIA f9pUPCES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> ,..,. �;► FORM C C•L,f OP NSP. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION h`I'A-,,'la � c2) 47—? 5- <br /> STREET :290S 1/. '56iQTAMW tk —"l— D;Qt I <br /> CITY !:�7vc.KTrlr� COUNTY f'4^) :IFV0 Q ul A) <br /> II. INSTALLATION (mark all that apply): <br /> Ld 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 /> VThe installation has been inspected and approved by the implementing agency. <br /> p/ All work listed on the manufacturer's installation checklist has been completed. <br /> 5/ 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent ' Dt —�Cjf�j/Rp� Date O 7--j0- �)'7 <br /> Print Name `F K4WD 69M <br /> / D Phone (5-10 ) 94Z_o)17 <br /> Address & DD 18,0L L/rj ",6- fin!�ON l� <br /> IA's �> -�� , CA 0)469.3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.#16 <br /> Z <br /> FORM C (M) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />