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ct—c(640 STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD AP °tip <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 L*Z44 E­ <br /> CITY S=C2C—\<_-_V_Cx-A COUNTY '---3AA-A JQt'�sQsJ1 1--_\ <br /> 11. INSTALLATION (mark all that apply): <br /> X The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> >4 The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 0 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 CJAE,-,�" Q?-q1:N3C:VECc-p Date C>S/Fat IRS <br /> -Print Name Phone (9 ) X�a k,756 <br /> -Address eo lz�ox 1,00C)4 ZA�V-A 9At-ACDT4 cjl�-,, 94S15z <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br /> 0 0 <br />