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STATE OF CALIFORNIA <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 �t �y O =tl- �! <br />CITY COUNTY <br />11. 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 />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 />Ill. OATH I certify that the information pro 'ded is2rue td the best of my belief and knowledge. <br />` <br />Tank Owner/Agent Date <br />Print Name „L �1 A4niA14;-c. /zj r Phone <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 1E <br />FOR0035C7 <br />FORM C 17191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />