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STATE OF CALIFORNIA • ESpURCES <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 <br /> i <br /> STREET 0 <br /> CITY _ZFe1L9C1,4 /�/� COUNTY - H �,-L400ji f <br /> II. INSTALLATION (mark all that apply): <br /> FA The installer has been certified by the tank and piping manufacturers. <br /> K 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> r <br /> Tank Owner/Agent��,V QA,Qu�,V / ��',¢L Date ©erj%Gfar <br /> Print Name �, �� — ?-P Phone (aOLI S— 4k.5 1 <br /> Address,5"&O rrsP/T'A RD (f,4^tP CCA, T6 1 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> I <br />