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STATE OF CALIFORNIA • f5py"CES <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION s o <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK <br />I. SITE LOCATION <br />STREET 9� Z l d W—,j til <br />CITY S-4 <- d j COUNTY <br />II. INSTALLATION (mark all that apply): <br />Tt�The installer has been certified by the tank and piping manufacturers. <br />D 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 />D Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent r ��,�„�G^; '^-:i S mkir Date (f Z <br />Print Name .��� /�2d,C�1cP J` e_ .6.VJ. / 'g Phone <br />Address 7 L`�.✓/e2�en • f � c�7 P r�•yi� CX FV 4Ve <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY" TANK # <br />TANK I.D.#1<101 613 zifil <br />II <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />