Laserfiche WebLink
• STATE OF CALIFORNIA PE o�H wes <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION f <br /> FORM C `•`" PY'' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET . 15) Ic <br /> CITY L. DO [��h (—Vk) <br /> �T� t—I QP COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer. i <br /> xThe 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 /> CI Another method was used as allowed by the implementing agency. (Please specify.) <br /> IIL OATH I certify that the information provided is true to the best of my belief and knowledge. �1 <br /> Tank Owner/Agent _ `�.�. , Date "jCv <br /> Print Name7j) C��..�-L11.�� _int-#f-� Phone <br /> Address T ko Lf«5�� CIT , [ !.UNI- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# y�� TANK# a <br /> TANK I.D.# D <br /> FORM C (7191( THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROOSC7 <br />