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)qo STATE OF CAUFORNIA pe®eyAe. <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 /> STREET 4-Z'S43--� 'F=,. <br /> CITY-..— K>C-�<QVA — COUNTY SNJ-A <br /> 11. INSTALLATION (mark all that apply): <br /> X 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 /> N�r 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 /> El 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 C-0 — -Date 0— <br /> ,Print Name VACV4Ej&.-"4 Phone (j2_5)8LW <br /> .Address f7c) ex>x Le-1001-Ar S&IT-A 9116-M OT-A (2-Al. 9L��Bf5 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I I I LLI I Ill <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br /> AND& <br />