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STATE OF CALIFORNIA ESo�Ares <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION as <br /> FORM �<crson H.s. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET _S r r-a ,.^e-v <br /> dQ <br /> CITY Vl COUNTY w J Qg-QU/rl <br /> it <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 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 /> 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 /> 111111. OATH I certify that the in or tion provided is rue to the best of my belief and knowledge. <br /> Tank Owner/ gent Date <br /> Print Name Phone (209 ) <br /> Address3//9 7V✓rye a 1k 6 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FT-1 EFT-1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />