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STATE OF CALIFORNIA <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 log <br /> CITY /`'I ah it C a COUNTY 511 t\1 �()t Lk n <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 /> ❑ All work listed on the manufacturer's installation checklist has been completed. <br /> ❑ The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> ❑ 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 - e Date <br /> Print NameP/10 Ld f2 l AfC- � Z-6-M 'hone (yLi ) `{) �� <br /> Address <<rVo Llf&) Oy✓ D4aVI%f CA 2 -0 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY* JURISDICTION# FACILITY# TANK# n <br /> TANK I.D.# F-F-1 --- <br /> FORM C (6195) THIS FORM MUST BE ACCOMPANWY PERMIT APPLICATION FORMS A&8 UNLESS THEY HIVEEN FILED PREVIOUSLY FOR0035C8 <br />