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STATE OF CALIFORNIA <br />STATE. WATER RESOURCES CONTROL BOARD <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 RolkM E: t -f f L04—S) t1v , <br />STREET 130 i W • k�Z`�LL/ti1�i l t.00v� <br />CITY ('001 COUNTY SAS Som Qy <br />II. INSTALLATION (mark all that apply): <br />egovRCEs <br />A� <br />3. o <br />• CSC/iORN�' <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 />�a 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 />111111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Address �%3 ,�iS,�E J, zv, <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I. D. # <br />Date <br />,— � k Im I] i n15 rUKM Mus I Bt ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />