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• STATE OF CALIFORNIA <br /> �SOVRCC3 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> 44 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> e a <br /> FORM C 4LFFo <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Qvl� STOP —76 <br /> STREET 103 S ALIVE ,AVE— <br /> CITY S-U0G�---7->/-) COUNTY S'I^) JOtt-QIJI tJ <br /> II. INSTALLATION (mark all that apply): <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 /> [� The installation has been inspected and approved by the implementing agency. <br /> �j 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 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 /> Tank Owner/Agent Date <br /> Print Name Phone ( ) <br /> Address <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 <br /> 0 0 <br />