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STATE OF CALIFORNIA Eso�«SEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W ,it, <br /> ppy ..FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> 4 � 7. <br /> ^' �4 FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION 6in-` i-DA) 0)4 2 ?6r <br /> STREET 2905- L- 5"-'j 1 Mt1j 900,-r PRI 1116- <br /> CITY 57-0 ck7-V A) COUNTY 54A) JVYqQa ll <br /> II. INSTALLATION (mark all that apply): <br /> F?( The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> E/ All work listed on the manufacturer's installation checklist has been completed. <br /> I/ The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 0 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 !� 1�t �C� �/jPOJv Date 02-)o-0) 7 <br /> Print Name Rt Phone (5—ID )R4 2_ 1 g <br /> Address CC 00 1 9011, )A) d <br /> �Aij R6-m0fj) Cn o)-458:3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F <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 />