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STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD pEso„A`s �i <br /> CERTIFICATION OF COMPLIANCE W �� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> Folz pin 6- SYS 7e-m ,8ein6— <br /> I. SITE LOCATION <br /> STREET PV-76 60. r9-12A^-'Z- <br /> CITY <br /> /ZAiv7CITY TLaQt COUNTY S/pAv 700gvi'17 <br /> If. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> F-1 All work listed on the manufacturer's installation checklist has been completed. <br /> Xl The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 17 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 /> Tank Owner Agent // _ Date <br /> Print Namey Gdc c� pCrmi j�5 mo/loa�2 Phone <br /> Address CLj <br /> /D LUai�on ain c-12112 2/1e* . <br /> 8yS 2!s/Ce.- !-UnG � 60ts7S&c/0A7"19 Ca 9569/ <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C pied THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />