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STATE OF CALIFORNIA fESouno.ga <br />STATE WATER RESOURCES CONTROL BOARD �P <br />9 <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION rs os <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET I boucoLO Tl -1000 al I <br />CITY d Id COUNTY <br />II. INSTALLATION (mark all that apply): <br />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 />D Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that - information provided • the best of my belief . • knowledge. <br />Tank • . s - r <br />Print _ jt?;,, * rgoEtJ Phone <br />f <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # <br />TANK I.D. # F.31 --q] <br />�. <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT <br />FO10035C7 <br />