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• STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION :. a <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 420 WtS- k6SCLCK'�ArA 1*J <br /> CITY Lb E) I COUNTY SAN SOAQvAIV4 <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 /> I All work listed on the manufacturer's installation checklist has been completed. <br /> oThe 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 /> 111. OATH I certify that orma ' ro i true to the best of my belief and knowledge. <br /> Tank Owner gent Date /z( AB <br /> Print Name Phone ( 125 A33-057 6 <br /> Address < <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# m El I I I 1 1 �7 <br /> FORM C (6/95) THIS FORM MUST BE ACCOMP*BY PERMIT APPLICATION FORMS A R 8 UNLESS THEYW BEEN FILED PREVIOUSLY FOM35CS <br /> L <br />