Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE ;W � <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C 17 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET t`1g31 �1 . F!ti— �^�*/ GWC) <br /> CITY COUNTY <br /> Il. INSTALLATION (mark all that apply): <br /> X 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 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 Date 7—/0.q7 <br /> Print Name"—c—_—,,V— ,Jt Phone (q/(�) 3-72—/17135' <br /> Address 3635 •-� t FAVp Lj . g56-j 1 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C prod THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A S 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FO60035Q <br />