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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 <br />/TANK SYSTEM <br />AL <br />I. SITE LOCATION <br />STREET C 3 2 <br />CITY V AJ COUNTY d <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 />14 The installation has been inspected and approved by the implementing agency. <br />Ee'AII 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 />111. OATH I certify that the information prqvioed is true to the best of my belief and knowledge. <br />Tank Owner/Agent ,,,.r,j< S-4 /444. Date <br />Print Name ,�1�.�� �if7rif�-��c� ,%2 rWa, Phone (S /0) X57-�5'C►C� <br />Address r 9` <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # f� 1 <br />TANK LD.# Q <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />