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STATE OF CALIFORNIA EyooA�eb <br /> STATE WATER RESOURCES CONTROL BOARD W+� otic <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET X)56 E014XL wH 11 <br /> CITY ry i n � COUNTY SP!yL rl I in <br /> II. INSTALLATION (mark all that apply): <br /> [r/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 /> FWT� The installation has been inspected and approved by the implementing agency. <br /> Lam- All work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified or 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 the ' form tion provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name �� cD Phone (1112 ) t7 9-6%,54 <br /> Address �.n)L 111!71 A01A u rH �( <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# M <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 8 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />