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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ` CERTIFICATION OF COMPLIANCE Wy . <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION j <br /> �•~ ., . .' . FORM C ° \•`',�,��r. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> .1. SITE LOCATION r=c000 l,ta {J` "1t3+�3G SµQ14 NC. 130 <br /> STREET �CA '?0EMS—T l.&J E <br /> CITY 5'Kboyl®t%N COUNTY- <br /> 11. <br /> OUNTY 11. INSTALLATION (mark all that apply): <br /> Q The installer has been certified by the tank and piping manufacturers. <br /> Q 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 /> 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 /> S <br /> Ill. 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 Phone <br /> Address !4411 eirCAAS"1R.0 IJrc (2."l 92C�r�� <br /> LOCAL AGENCY USE ONLY <br /> I STATE COUNTY# JURISDICTION s FACILITY a TANK is, <br /> j FM1-17--1=7711 I 1 I �1r�II- I 7 <br /> TANK I.D.# <br /> FORM c hreil THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FQR0035C7 <br />