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STATE OF CALIFORNIA es°uRc <br /> STATE WATER RESOURCES CONTROL BOARD �P P cuaee �O� <br /> CERTIFICATION OF COMPLIANCE W ,�? <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s °� <br /> FORM C s <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 0 ( Li C -r 7-t, <br /> CITY i COU 100 IQ v <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> F-1 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 /> FW 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 /> E:1 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 Owner/Agent , Date -6 9 <br /> Print Name C 4A(Ljes o+o ars1 Phone ( 2.a } _®74 6 <br /> Address qzo o eS C- V0 s ' 6 it <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c7 <br />