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• STATE OF CALIFORNIA pee°�^Os <br /> STATE WATER RESOURCES CONTROL BOARD <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 <br /> CITY S�bc�l �oN COUNTYn, S6�ofu`N <br /> If. 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 /> Xj 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 /> W)tt . V6 4\ ,.\e 'Cb a\\ z) \jS-eS cA� <br /> � ,c off. \Te . <br /> Ill. OATH I certify that the information provided is true tot bes of my belief and knowledge. <br /> Tank Owner/Agent AYCti Qfr�\ CO • 1� Date 311-)15$ <br /> Print Name \ - Phone a <br /> Address P 3 8CA1u2 -ba 3� <br /> LOCAL AGENCY USE ONLY <br /> STATECOUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7M) THIS FORM MUST BE ACCOMPW BY PERMIT APPLICATION FORMS A&B UNLESS THEYE BEEN FILED PREVIOUSLY <br />