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STATE OF CALIFORNIA . �zw^cea <br /> STATE WATER RESOURCES CONTROL BOARD �P '�"'"" o+a <br /> CERTIFICATION OF COMPLIANCE W ; <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION 'sr <br /> FORM C "° <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION / <br /> STREET � �� � - �1�11. (�lK� Oa <br /> CITY G COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> IC The installer has been certified by the tank and piping manufacturers. <br /> F-1 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 /> >CThe 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 /> t <br /> Owne Agent DateS Mq?, <br /> Name C n ' h hone ( ) , <br /> Address 0117,q S b <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# 71 TANK# <br /> TANK I.D.# <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORM5C7 <br />