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etATE of CALIFCNN!A <br /> STATE WATER RESOURCES CONTROL BOARD �•• , <br /> CERTIFICATION OF COMPLIANCE 0Vy <br /> t } <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C ' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> fi <br /> I. SITE LOCATION ArOdeAP 40 634�72—C:) <br /> I <br /> STREET j p4 em1'ra W�. <br /> CITY WA T" +r„` COUNTY 44414 ja;^Mu 3 P11 <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 enoinee,. <br /> The Installation has been Inspected and approved by the implementing agency. <br /> LA All work listed on the manufacturer's instailatlar Checklist has been completed. <br /> The installation Contractor has been certified or licensed by the Contractors State L!Ccnsa Board. <br /> Another method was LSed as allcwed by the implementing Agency. (Please specify.) <br /> I <br /> I <br /> III. OATH I certify that the information provided Is true the est ofi9f and knowledge. <br /> Tank Own19Nq.�, Oate `� <br /> Print Name "' <br /> I Address . - 4 4y' d <br /> LOCAL AGENCY USE ONLY <br /> STATE COL;Nry JURISDICTION t1 �����FA`C``ILIT f a_ TANK 0 <br /> TANK I.D.# FL L_L�77' �. I 1 I-1 <br /> FORM G c7jo+) THIS FORM MUST BE ACCOMPANIED BY OERVT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PFEYIOUSLY FcAcroser <br />