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. STATE OF CALIFORNIA • ovicea <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION sr . <br /> FORM C " (!: 28 <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET S55D SarA.-rL i{AZh 0101 <br /> CITY - 4ILU fit COUNTY 4 v 11 <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 /> EPrThe 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 ' formaionprovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent �cDate <br /> Print Name 'AnPhone A A2 ) <br /> Address fe <br /> LOCAL AGENCY USE ONLY <br /> STATECOUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (W91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORomsCT <br /> 0 0 <br />