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• STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD'(?' r <br />.T <br />CERTIFICATION OF COMPLIANCE NEAi <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />S4 FEB 23 PM I: 31 f ° <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET . �7Ou<-'7n 10 <br />CITY ::2 PO t1i COUNTY �12A & y l fj <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 />❑ Another method was used as allowed by the implementing agency. (Please specify.) <br />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent Dated <br />Print Name YA 0 t L Phone p ) $�C�-963 <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# JURISDICTION# FACILITY#T TANK# 2 <br />TANK I.D.# ® L Q 4(A - <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY J FOR9035C7 <br />