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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 15 2y FNE-CN6 A Vf-N4 -, S20c d <br />CITY STo c,k-To- r1 <br />II. INSTALLATION (mark all that apply): <br />COUNTY 5&- J44-QUIIN <br />1�1 The installer has been certified by the tank and piping manufacturers. <br />C The installation has been inspected and certified by a registered professional engineer. <br />i ° <br />o <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 and licensed by the Contractors State License Board. <br />C Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certifv that the information provided is true to the best of my belief and knowledge. <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # FG I I ' I U <br />FORM C (6/95) THIS FORM MUST BE ACCOMP "TD BY PERMIT APPLICATION FORMS A & B UNLESS THEv 'E BEEN FILED PREVIOUSLY FOR003SU <br />