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STATE OF CALIFORNIA f ye�•<<s <br /> STATE WATER RESOURCES CONTROL BOARD 0 <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY��'��I C A COUNTYeg I <br /> II. INSTALLATION (mark all that apply): AUG 0 1999 <br /> The installer has been certified by the tank and piping manufacturers. <br /> L=N'VPE MIITLTH <br /> ISERVICES <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 /> [K""'AII work listed on the manufacturer's installation checklist has been completed. <br /> EO'-"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 /> 111. OATH I certify that the informati ided Is ue to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name tic G'c7•,/Z�/ES, . _ Phone ( Zofl, 5I711-299'V <br /> Address ?6C7 io&We-,e --f72Pc'K-j-v.j; 44 j 3- i <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY#m TANK# j <br /> TANK I.D.# I I I � <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROMSC7 <br />