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STATE OF CALIFORNIA PE Sc�"wEs <br /> ` STATE WATER RESOURCES CONTROL BOARD <br /> ' CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION w :� <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Dr <br /> STREET C/ G`r.rc-aJe ro t ✓ p <br /> CITY �S" to C/c to v► COUNTY ,rGs„-y To cc. Gr cc of 4 <br /> II. INSTALLATION (mark all that apply): <br /> 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 /> Lk The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the inf rmation provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 1-6t” dc� ?-ff SG k^ , ;.'c e r Date ,Z c) Z <br /> Print Name z e f �6 C k Y Phone ( Ze)( q'o/.y <br /> Address to 6 V 9 —64, bwc,aJr ,a Do - <br /> .S-triC-k(u..*) C4,, 9' 6-;z 1 9 <br /> LOCAL AGENCY USE ONLY <br /> STATE (,L'l� COUNTY# JURISDICTION# FACILIT/Y�# TANK# �1G <br /> TANK I.D.#' V I leiD d 06, <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR00357 <br />