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STATE OF CALIFORNIA40 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE _ U <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ++ II /� <br /> STREET r� `1 Yo S F/") n, An — <br /> CITY M IIHTE C A COUNTY SEW <Z A Q,U 1 h( <br /> II. INSTALLATION (mark all thatapply): <br /> 541 The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> 0 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. f� <br /> Tank Owner/Agent C Date 6 <br /> Print Name hone ( 0) 5,/L _ <br /> Address Yo ,$ <br /> YYML - a 00 p£NA ,L0 &e0QNvL YYIo►��SN) CR 953 s6 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOF00I5C7 <br />