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STATE OF CALIFORNIA �ESo�wrEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I, SITE LOCATION <br /> p� r <br /> STREET qq IJ LA,+ L-44W C� � Iy6b Q—J06- <br /> CITY SL-41U (—A • COUNTY !n,J <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 /> 5Z 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 /> 111. OATH I certify that the informationvi d is true tp44 bi#t of my belief and knowledge. <br /> Tank Owner/Agent Date 3 -10 <br /> /+0 <br /> Print Name "� ,r'� f. `vt o C� Phone <br /> Address 16D Sa" Viu P-,4 t1 V944-hu-&A- L` <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION FACILITY# TANK# <br /> TANK I.D.# L. F1 <br /> FOFiM C (7/9 1) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 9 0 <br />