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• STATE OF CALIFORNIA • Es°�Rces <br /> STATE WATER RESOURCES CONTROL BOARD AP" <br /> CERTIFICATION OF COMPLIANCE W01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION :0 <br /> FORM C <br /> R&CO" -k Od LES - I-A7\)k Z <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION �I'A-rio^J 0)4-Z -7-5- <br /> STREET <br /> )4Z7SSTREET 2 )05 W, ff"I A-""1N NO I-"- R 1 lSE <br /> CITY -,/`rD Ck `r COUNTY 151tl� 3—b (4 1 N <br /> II. INSTALLATION (mark all that apply): <br /> dThe installer has been certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer. <br /> [Yj The installation has been inspected and approved by the implementing agency. <br /> EV( 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent j J3 , / CAL6 js)'0Aj Date b 2—l b c) 7 <br /> Print Name 'R 1 raj.{ W—b 8, GAP l-� Phone (S'je ) Z-Cj I"78 <br /> Address &001 BOL ,.! YJ R <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F-F-1 I I I I I I I Lllq .l!�l Z�Q 10 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />