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r <br /> STATE of CAuFORMA <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 /> j I. SITE LOCATION (lin <br /> f7 <br /> STRE ET <br /> CIT �fu�IG�� (',li� COUNTY 8216 <br /> II. INSTAL AT10N (marl[a1 that app;y): <br /> Tie installer has been certified by the tank and piping manufacturers. <br /> t- <br /> T,,,?, installation has been inspected and certified by a registered professional engineer. <br /> T ,e;nsWa ation has been inspected and approved by the implementing agency. <br /> A I A,crk listed on the manufacturer's installation checklist has been completed. <br /> i T ie installation Contractor has been certified or licensed by the Contractors State License Board, <br /> C_. A iother 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 fes_ to C� Z7/UC Date LO <br /> Print Ne me2 .r _ G7 —$GQO <br /> Phone <br /> Addres ---— <br /> I LOCAL AGENCY USE ONLY <br /> STATE COUNTY n JURISDICTION x FACILr Y x TANK x <br /> ro v irei) NIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICAT!ON FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROW5C <br />