Laserfiche WebLink
I <br /> STATE OF CALIFORNIA <br /> Uqc <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> • C�t.tiq NSP. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET CfC l LJc" I&AD <br /> CITY -Srad:Xa[ COUNTY SaJ 169c.. uit..l <br /> II. INSTALLATION (mark all that apply): <br /> p�r The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> J�< All work listed on the manufacturer's installation checklist has been completed. <br /> >!C 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 th information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agen114` ,� cap. Date &67/13 <br /> Print Name ("I ;u p.�� Phone (-7a-1 <br /> Address nn A ric- C6, ,,ft-.— Rz5'rA,-Ltm,A , C.�. c4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ <br /> 16 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />