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STATE OF CALIFORNIA • Eeoo.�es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONSO <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM E <br /> .<z <br /> M 17 <br /> I. SITE LOCATION <br /> STREET 120 N V✓ -I4 <br /> CITY G✓l 4 SCA COUNTY <br /> ll. INSTALLATION (mark all that apply): <br /> X 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 /> E] 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 �j�6 Cc,c�F UGC Date 3_ ( 1_9Z <br /> Print Name _ sa>` Phone <br /> Address 'P. <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOFaossci <br /> /3D �S <br />