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STATE OF CALIFORNIA \10 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W k; <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> F <br /> TE LOCATION {� <br /> STREET <br /> CITY S\& COUNTY <br /> OCT 0 7 1998 <br /> II. INSTALLATION (mark all that apply): <br /> ENVPROINIMIS TRVIVICES�H <br /> The installer has been certified by the tank and piping manufacturers. <br /> v�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 /> The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> O 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 MA.N�;CY i 4 crv� tier/yG _ Date f0, <br /> i <br /> Print Name b ������ Phone (.2o <br /> Address Ugh / Al l� � �• ��, � (2��n! �,,� CC -:2 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# �� J[/ <br /> TANK LID # F17 � 11,540 —I 11 <br /> FORM c pisil THIS FORM MUST BE ACCOMP LAMED BY PERMIT APPLICATION FORMS A&B UNLESS THEY WAVE BEEN FILED PREVIOUSLY FOROP 7 <br />