Laserfiche WebLink
G <br />• 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 t`- � 6. 11 oto L0 <br />CITY s o Gg=�1) COUNTY SAw JIC)Prq o' --I <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 />t< The installation has been inspected and approved by the implementing agency. <br />PE gOV aCES �` <br />P 'Jr <br />ti 9 <br />t O <br />3 �p <br />w .TS n�i J <br />0 All work listed on the manufacturer's installation checklist has been completed. <br />F34 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 information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent Q F ;�TO C �j-a,,j Pt/.6) 1 c- WKS, Date 4,1 <br />LOCAL <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ItFi 3 3 .2 S <br />FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />0 0 <br />