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STATEOFCALIFONiA <br /> STATE WATER RESOURCES CONTROL BOARD T� <br /> CERTIFICATION OF COMPLIANCE W ,� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOC kTION <br /> STREET �(r� Al 811V, 9`1 <br /> CITY 50t4-(� �'� COUNTY <br /> 11. INSTALL kTION mark aM that apply); <br /> (�f1 <br /> Ttie installer has been certified by the tank and piping manufacturers. <br /> T1 e installation has been inspected and certified by a registered professional engineer. <br /> Tt e installation has been inspected and approved by the implementing agency. <br /> A work listed on the manufacturer's installation checklist has been completed. <br /> T e 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 /> 111. OATH certify that the information provided is true to the best of my belief and knowledge. <br /> Tank 0 wner/Agent �� y ,(� Date fQ c_ <br /> Print Name�G ��r / Phone ( ria ) <br /> Addre �d _ 2 `' t WtSS s, `Z - <br /> LOCAL AGEN Y USE ONLY <br /> STATE COUNTY# JURISDICTION A FA(C�ILITYY 8 TANK# <br /> TANK I D. � L_L__�' <br /> FORM C cl"911 THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY Foams <br />