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STATE OF CALIFORNIA 111911 <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION `i �i� d�� e A-/ C 4-1,c < e9•J <br />STREET <br />CITY .SG%/�2Qn. C1�r ��o COUNTYY- LJ <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 />f,45olrgrES <br />t � o <br />Cil t. �p N'r <br />❑ All work listed on the manufacturer's installation checklist has been completed. <br />L--l—The installation Contractor has been certified or licensed by the Contractors State License Board. <br />1-1 Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent j s�,����prr �� Date <br />Print dame�- <br />Phone <br />Address :5e'-4S4P <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # Erl <br />zs rr IQ 94 <br />^ + i hit, rUnM MU.b i tit AUGUMF'ANItu dY NLHMI I APNLIUAI IUN FUHMS A 3 9 UNLESS THEY HAVE SEEN FILED PREVIOUSLY FOR003507 <br />0 0 <br />