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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Eeoo+`Ee <br /> CERTIFICATION OF COMPLIANCE 3P <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION 1 f / <br /> STREET gaq � Y0Q/YTStTE (�V& <br /> CITY �- F)tN f4— C A COUNTY SA Pr (7 \1 t n) <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 /> [f 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 /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent ) F401 �)As T G� Date3—� � <br /> Print Name L_ YY1 S ( ) q -() r , <br /> Address t T CSVVRRRR�� `I b <br /> YnA L.- as o 0 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY <br /> ��TANK I.D.# m <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROW50 <br /> 0 0 <br />