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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W m o <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> 7— eLt,r-,,jc.,t-j lb �- <br /> STREET l to Z2 -V k ,r1 .D g <br /> CITY g �- : r,1 COUNTY <br /> II. INSTALLAT N (mark all that apply): <br /> e installer has been certified by the tank and piping manufacturers. <br /> T e installation has been inspected and certified by a registered professional engineer. <br /> The installation has been inspected and approved by the implementing agency. <br /> work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the infor ti ov is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date (1 <br /> Print Name ZY' Phone (� ) <br /> Address 11 L <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (6/95) THIS FORM MUST BE ACCOqP IED BY PERMIT APPLICATION FORMS A&B UNLESS T VE BEEN FILED PREVIOUSLY FOA0035C8 <br />