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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 <br />STREET Loko-113 6&,C..\ E k C— AWEr» <br />CITY `3 oCjo�a> y -A COUNTY �Aa ❑oAQy�t� <br />II. INSTALLATION (mark all that apply): <br />x 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 />❑ Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the i formation provided is true o the best of my belief and knowledge. <br />Tank Owner/A Dated►-E/t 3 Ia8 <br />Print Name BE -t-kAe Phone (92-t))6lA-2- q b b <br />AddressGNE�/(2p� �12o�yCTS CoM�A�1l� <br />F0 6ox �OeXDq C-�N 2&4�tot-.1 CA q' -Y583 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # r`T <br />TANK I. D.# 9 El h 5 I <br />FUHM c (7191) THIS FORM MUST BE ACCOMPW BY PERMIT APPLICATION FORMS A & B UNLESS THEY W BEEN FILED PREVIOUSLY <br />