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• STATE OF CALIFORNIA • pcsoo^=cs <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!/`j n <br /> STREET WOO S- Afr�u► I.VaY <br /> CITY -S10ej< n COUNTY Sdn <br /> II. INSTALLATION (mark all that apply): <br /> dThe 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 /> D 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 A � Y Q Ver eendek Date <br /> Print Name '/p ,� �inz�IL�1j Ph/otneQ(�Dr� ) Q (jib <br /> Address T-DU <br /> LOCAL AGENCY USE ONLY <br /> STATE rCOUN��TY# JURI�SDICT�IOJN# FACILITY# TANK# <br /> TANK I.D.# I <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />