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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 P11jZ,q <br /> STREET Soo S. �NEeoCt�= Lsan/E <br /> CITY L" COUNTY -54N So.4FyVII/ <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 /> E] The installation has been inspected and approved by the implementing agency. <br /> O 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent /C20A/ rA6�L .9&.vi Date 3 /// 1�y <br /> -- <br /> Print Name ,LON M46,q , Phone ( 9/G ) fSSt <br /> Address Sl9/ /3ct ,eE ASE s d s�� eq 9s8� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# lu <br /> FORM C (7/81) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FoRo095C7 <br />