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STATE OFCALIFORNIASTATE 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 39 7.5 E, /f/GN WAY 8� <br /> CITY LDcKEFog COUNTY SRN JOA 0L)W <br /> II. INSTALLATION (mark all that apply): <br /> ❑ The installer has been certified by the tank and piping manufacturers. <br /> O 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 /> 0 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 /> ❑ 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_ (/GT-R,4ML4& INL Date //-30-9 9 <br /> Print Name j OHIV (/A6-r Phone (5� ) 593 3235 <br /> Address ij 25 V/• THIRD 51-• ff4A/FOR 9 C,+ 932 30 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (]51) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A d B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />