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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> is <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET `120 Y,4F.& kF-Tr EN\Av.1 LANE <br /> CITY L-C)t-)l COUNTY 7'OA©M%,0 <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. <br /> C The installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturers installation checklist has been completed. <br /> XThe installation Contractor has been certified and 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 r nr 1 e to the best of my belief and knowledge. <br /> Tank Owner gen Date <br /> 2 8 <br /> Print Name Phone (qts1A -OS 78 <br /> Address 4109 , 1 S <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY A JURISDICTION k FACILITY a TANK a <br /> TANK I.D.A m —� <br /> FORM C (6/95) THIS FORM MUST BE ACCOWIED BY PERMIT APPLICATION FORMS A&B UNLESS T —4AVE BEEN FILED PREVIOUSLY FOR0035CS <br />