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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 TANK SYSTEM <br />I. SITE LOCATION O v kIF— 5Tro P M,AQ- t7r *- I Z 1 <br />STREET I I o((o W6S7 L-00 ISE AVB - <br />CITY M R/J -re- - COUNTY <br />II. INSTALLATION (mark all that apply): <br />SA^j ZC0�-c;>- Ur nJ <br />KThe installer has been certified by the tank and piping manufacturers. <br />F-1 The installation has been inspected and certified by a registered professional engineer. <br />F --j 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 />DK' 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 />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent <br />Print Name <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # FFI <br />Date <br />Phone ( ) <br />JURISDICTION # FACILITY # TANK # <br />, rno rwnm mea i CC Al.6Umt'AN1tu bT YtHMI I AFFUUAI lUN FUHMS A& B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />