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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 FU& E- t- I QV 0PQS i q,' G , <br />STREET 1301 W. K67 -(C6 MA,-,) LA) <br />CITY <br />LLo 0 <br />II. INSTALLATION (mark all that apply): <br />COUNTY <br />�E50URCES <br />3 <br />' iEo <br />• C'�t IFpP N1► <br />�K The installer has been certified by the tank and piping manufacturers. <br />71 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 />Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Ow E <br />Print Name <br />Address 53y3 eeLSle,5 IA-) /z% !:i�¢G <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # <br />-- � t y lr I h1b runM nous I Bt ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />