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L Q/vl, <br />I. SITE LOCATION 1'301 <br />STREET <br />CITY <br />STATE OF CALIFORNIA Is <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 />� L 16.V DR -S , 1 N C, <br />W. 07 -CC 6WW J LAAO <br />II. INSTALLATION (mark all that apply): <br />COUNTY SA -A/ SOA-'�-' V f ej <br />N5ouaces <br />P <br />AP w <br />4 <br />3 <br />a v> <br />s�� o <br />��tiFoa N.v . <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 />1W The installation has been inspected and approved by the implementing agency. <br />2!17 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 />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank OwnE <br />Print Name <br />Address ewl 6 <br />LOCAL AGENCY USE ONLY <br />Date Q/g. Ak/ <br />Phone (,j/,6 <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ <br />1--. � V-1 i nls runM mus I lit ACUUMPANIELI BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />