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' STATE OF CALIFORNIA o�°Oea <br />STATE WATER RESOURCES CONTROL BOARD' <br />W ti� <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION r1EALT11 as,> <br />FORM C 114 FEB 23 PM I: 31 <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET0100 <br />�S —} % , <br />CITY /C100r,) COUNTY _?4N (-,i LQtn) <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 />d All work listed on the manufacturer's installation checklist has been completed. <br />E,?�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 00 Date,,` —& <br />Print Name L Phone 620 <br />Address -71S — MOV .STD 95351 <br />LOCAL AGENCY USE ONLY <br />STATECOUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ® 1 I -f 1 1 �0-4 D /'e-- <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FCd0035C7 <br />