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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE t �, <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION w ' <br /> f� <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION f,��i j <br /> A <br /> STREET —90d L'e"ic— I}'noeAJO, <br /> CITY SFa-LlT rJ _ COUNTY -544 —n6LLl,-,j &,L.J4 <br /> II. 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 infor rovided is true to the b st of my belief and knowledge. <br /> Tank Owner/AgentDate /Q -- <br /> Print Name ��e-k- - 4U �Lk Phone <br /> Address [j Lx rz/J A, Njz,c.�t"r r �, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM 0 (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003507 <br />