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STATE OF CALIFORNIA <br /> f SpU vc Es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE '- <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a - <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION , J ,, <br /> STREET d`�/ � ZJ "�"� <br /> CITY —6-16CLLo 61 COUNTY -�-^— <br /> IL INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> J The installation has been inspected and certified by a registered professional engineer. <br /> [Y� 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 /> CJ Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date J-10—q.5 <br /> Print Name �} � p,�jPhone <br /> Address 16D 54M bue-tJA <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> I Ll TANK I.D.# F= FTT FFTI <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR009SC7 <br /> is 0 <br />