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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD • <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> • FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET L, <br /> CITY AN I F (' f� COUNTY _ c�)A <br /> II. INSTALLATION (mark all that apply): <br /> [✓f 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 /> • [v� All work listed on the manufacturer's installation checklist has been completed. <br /> [v� 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 /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent T)-b ry1 ks T-�,X( C.o Date <br /> Print Name K0) yn pL 0 m Sone <br /> Address Ti C - <br /> MPdL_ f, aaoo oQ4/NOVO"Z �w2. Y11� �J�Sv-o tC� 85356 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7A1) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A R B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0077 <br /> 0 • <br />