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STATE OF CALIFORNIAp„ora=y <br /> STATE WATER RESOURCES CONTROL BOARD wool +� <br /> CERTIFICATION OF COMPLIANCE <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 /> CITYCOUNTY ^ <br /> 1 + O <br /> 11. INSTALLATION (mark all that apply): OCT 071998 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> V"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 /> [!?r' 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 AIAAin!✓ 4f' Date /0' 6'- 9� <br /> Print Name Xgle;r/wA Al azo r Phone (0205' 67�/�' <br /> Address 4�p / ,N �crQ ,..._ T��la,c, `�� ” <br /> 07 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK* <br /> TANK I.D.# 5t r76719N . 0,13.1 <br /> FORM C (W91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FIXi9D 7 <br />