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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE n <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> m- <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET LI-2-0 \ J&JKT kEr L: tiNWA 14,af <br /> CITY LbD I COUNTY SADA SOAQ,Al " <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 /> The installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> �KThe installation Contractor has been certified and licensed by the Contractors State License Board. <br /> I Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. O;Tank <br /> H I certify that orma ' n ro i true to the best of my belief and knowledge. <br /> i <br /> Owner gent Dateint Name Phone ( 125 ) 133-0576 <br /> Address < <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# J((URI��SDICTIIO�ON�� # FACILITY# TANK# <br /> TANK LD.# � I_�J I I I <br /> FORM C (fi195) THIS FORM MUST BE ACCO&IED BY PERMIT APPLICATION FORMS A&B UNLESS TIOAVE BEEN FILED PREVIOUSLY FORM35CS <br />