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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION Id <br />0 <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET e -r -V( -�C L—I e— <br />CITY COUNTY 7� 06L <br />111. 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 />[kr�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 />Tank Owner/Agent Date 5 1 � ;;— <br />Print NameUU 2-01 <br />PVO&f X-0� -A-� �A i Phone ( <br />as.-, <br />Address S2,5 W , --\, j 9-lrc—e- 4 q �2 30 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # F -F] = I I I I I I <br />FORM C (7M) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORD035107 <br />