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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 22o5r <br /> CITY -5;t-S UJ—�A COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> F--j 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 /> F—] The installation has been inspected and approved by the implementing agency. <br /> D All work listed on the manufacturer's installation checklist has been completed. <br /> E:] 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 infor of my belief and knowledge. <br /> Tank Owner gent .1& Date 7—Ig,15-- <br /> Print Name Phone (4716, <br /> Address 7W- <'r. ' 4�4-4 0,4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />