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STATE OF CALIFORNIA 0 <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 TANK SYSTEM <br />InIAl -/4-C4 670 <br />I. SITE LOCATION <br />STREET !1.30 - r�� ktz=.5�. <br />CITY `��l AIA 1W CA COUNTY n-' 904 / tj <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 />E:1 Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the information provided is true to the best of my belief and knowledge <br />Tank Owner/Agent <br />Print Name 4 <br />, 5� -6zG <br />Address �r <br />LOCAL AGENCY USE ONLY <br />Date d &V <br />n <br />Phone <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # <br />FUHM U Itr9lI THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />0 0 <br />