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STATE OF CALIFORNIA a zoo a=es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W °lit, <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s ° <br /> ;�._. FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> �R,E41 uM tlnl l- _ -r?W k :;t- <br /> I. SITE LOCATION �-r-n-'i--)cW 947-75- <br /> STREET <br /> 4775- <br /> STREET 20)05 k/o f?6 JJ"R-M f /J 001-`T PR 1✓� <br /> 01 CITY �� -no <br /> COUNTY <br /> I1. INSTALLATION (mark all that apply): <br /> dThe 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 /> [V' 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 /> 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 Date 0 Z- /0- 0) 7 <br /> Print Name WL CAA-RD t &A-P-R 0 --r Phone ( 5-yo ) $ Z-9 j 78 <br /> Address 62 0 0 1 8 0 LL J rJ66_R C*A1 XV/J <br /> 6�4-f\1 IZ ft"rA-nAJC-A (D-45-0 3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# V.)" <br /> TANK I.D.# 7_1 ❑_ <br /> 16 <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 />