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STATE OF CALIFORNIA Eso�Rces <br /> STATE WATER RESOURCES CONTROL BOARD e" '""'"' •`�ti <br /> w ? <br /> CERTIFICATION OF COMPLIANCE 301 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK S3&1kt1%AVt1 <br /> 5 <br /> I. SITE LOCATION ENVPERMITISE�ICESLTN <br /> STREET <br /> CITY C�it� TfXA COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> E] 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 /> ]y�—AII work listed on the manufacturer's installation checklist has been completed. <br /> J�J--The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the information p ovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name <H;'�� j C1 f-JA�f— Phone (T1S'7 <br /> Address p 7 11701 <br /> LOCAL AGENCY USE ONLY PZZI <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# All }(-1911 Li 3 ✓1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />