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Rug 28 98 03:07p Elite IV Contractors Inc. <br />00-29-1998 12:171AM FROM • TO <br />209-461-6342 <br />• 4616342 P.02 <br />STATE Of CAUFMIA <br />STATE WATER RESOURCES CONIAOL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />0 <br />p.3 <br />I. SITE LO <br />ATION <br />STR&ET�OTi <br />C / <br />er? S l �� t� g�� ��4e) <br />CITYI <br />Jc 1 c � v.s a A,, COUNTY - 'o Cc. i c 1 7Z <br />11. INSTALI <br />-ATION (mark all that apply): <br />I <br />he installer has been certified by the tank and piping manufacturers. <br />)ESTlhe <br />installation has been inspected and certified by a registered professional engineer. <br />TlfIhe <br />installation has been inspected and approved by the implementing agency, <br />n work listed on the manufacturer's Installation checklist has been completed. <br />may, The <br />installation Contractor has been Certified or licensed by the Contractors State License Board, <br />L i <br />nother method was used as allowed by the implemenling agency. (Please Specify,) <br />i <br />I <br />I <br />i <br />Ill. OATH <br />certify that the information provided is true to the best of my belief and knowledge. <br />Tank <br />wne F-. rJ es s or e r Date 0 8 s2C3- iR <br />Plint Name <br />�0. c /< o f Fe / tr e -A %/ Phone (9�09 ) <br />Addre <br />s rn A % A 7-,5,K 9.5'2 0 S <br />I <br />//.°' <br />LOCAL AGENFY <br />USE ONLY / <br />STATE COUNTMn J�UaSD�IC7r*N� v FACILRVA TANKi <br />TANK I.D. 41 IT—T-11 <br />i <br />FOa C(7V,, TNS FORM Musa HE ACCnMGAMM ev xo..,. .,.ti ........, ._ <br />TOTAL P.02 <br />