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STATE OFCAUFOMA <br /> STATE WATER RESOUACES 00WHOL BOARD " <br /> CERTIFICATION OF COMPLIANCE ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> I <br /> FORM C <br /> COMPLETE SEPARATE FORM FOR EACH TANK SYSTEM <br /> I.SITE LOCATION ,l> e,2 '�'°!4 t`w'o"'� A14 9'z <br /> STREET JZ0 4-'�2 , � <br /> CITY �—'l��"7`� COUNTY <br /> II. INSTALLATION (marls all that apply): <br /> The Installer has been cartifled by the tank and piping manufacturers. <br /> O The installation has been inspected and certified by a registered professional engineer, <br /> ., The installalion has been Inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed, <br /> The instai!atlon Contractor has been certified or licensed by the Contractors State License Board. <br /> C� Another method was used as allowed by the Implementing agency, (Please specify.) <br /> Itl.OATH I certify that th of rmatlon pro Wed s true to the best of my belief and knowledge. <br /> Tank Own r <br /> Data ff <br /> Print Nance f Phone <br /> -� <br /> Address G t r �tl �� + 'I7 l �t ' C.�f 41/%� J <br /> LOCAL AGENCY USE ONLY <br /> 8TATE CCRRVTY i JURISDICTION M �FAACI� <br /> CILnY s'' TANK� <br /> TANK 1,10, L_�J—J I f I I IIV J1 <br /> J <br /> FOFIM c 471211 THIS FORM MUST BE ACCOMPANIED BY PERMIT APFUCAMR FORMS A 15 UNLESS THEY HAYS BEEN FILED PREVIOUSLY Fa+omsc� <br />