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STATE OF CALIFORNIA <br /> ♦W1 STATE WATER RESOURCES CONTROL BOARD p i <br /> CERTIFICATION OF COMPLIANCE W u <br /> FOR UNDERGROUND STORAGE.TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREETM97 4 e57S e-,rnL`E'A <br /> CITY ."/1 f e Ccr COUNTY 411 0!5 tj Qa, <br /> ll. INSTALLATION (mark all that apply): <br /> ce/The installer has been certified by the tank and piping manufacturers. <br /> Q'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 /> �he installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D 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 C Date —J-'0 <br /> Print Name � y Phone -- ) 3oZ0 SSS <br /> Address a®FV/& 4,0PAAKe7 Al,ro twee, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.'t F <br /> FORM C(7MI) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 9 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FoaOmsci <br />