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STATE OF CALIFORNIA PEgo q�;s c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 92-11 LIl kg%A t7 <br /> CITY -5=r-l291 COUNTY '6+1 2--4 -AlhA <br /> II. INSTALLATION (mark all that apply): <br /> � 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 /> 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 /> Ill. OATH I certify that th Information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent of �. Cap. Date g 27/q7 <br /> Print Name Phone (74--j )7b5—/&e <br /> Address ts31 kj. 4c- 06,,, ova. _ RzrA,-LtmA , C.�. ce4crs� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# (�FACILITY## TANK# <br /> TANK I.D.# FF16 <br /> I I I I <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />