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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE w 'k <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION 11 <br /> STREET �Z!75(2, <br /> CITY COUNTY COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> [ The installer has been certified by the tank and piping manufacturers. <br /> EVI The installation has been inspected and certified by a registered professional engineer. <br /> VThe installation has been inspected and approved by the implementing agency. <br /> M/AII work listed on the manufacturer's installation checklist has been completed. <br /> Eel The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 0 Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name U C Phone <br /> Address 2111,4_4/,F�• <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> FF <br /> TANK I.D.# FFI <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />