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• 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 n��� <�V S`ToCIC-m,� ��— <br />CITY Z qQ'I COUNTY �S(-a j (VP 12 0` hi <br />II. INSTALLATION (mark all that apply): <br />❑ The installer has been certified by the tank and piping manufacturers. <br />F7 The installation has been inspected and certified by a registered professional engineer. <br />dThe installation has been inspected and approved by the implementing agency. <br />�AII 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 />E::] Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information pr vlded is true to the best of my belief and knowledge. n <br />Tank Owner/A ent 1 -� Date g—O—`7y <br />Print Name v�/1 Phone poo) Sag-Usl <br />Address )a 1��% — C'T r r �n Q r�EJ�`Til I CA ,, rt 5 S lj <br />LOCAL AGENCY USE ONLY <br />�� P <br />STATE OO�N1Y tl J URI IS�IOTIO`N N FACII�I� TANK # � �`1 <br />TANK I.D. # " I-��� ILL`1Lj��l y 14 <br />2a7� <br />cnou c 11.11 <br />niw i Dc-=)MPAMED BY FEAMi i AFFLiu l IUN tUKW A& B UNLESS THEY HAVE BEEN FILED PREVIOUSLY ' FOR0035C7 <br />0 9 <br />