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0 <br /> STATE OF CALIFORNIA '6,p.-Ce <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 100 <br /> CITY ec-CA- COUNTY Lktl q I o <br /> 11. INSTALLATION (mark all that apply): <br /> F-1 The installer has been certified by the tank and piping manufacturers. <br /> F7 The installation has been inspected and certified by a registered professional engineer. <br /> 7 The installation has been inspected and approved by the implementing agency. <br /> F-1 All work listed on the manufacturer's installation checklist has been completed. <br /> F7 The installation Contractor has been certified and 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 Date <br /> Print Name UALAIF-ft AIC- 6-M 1-C 0 MADVI� Phone qjj-) <br /> Address W7 4Z ki'JI)LLYI�W NIC Da A)vi 11f cia qqu) <br /> V <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY* JURISDICTION# FACILITY TANK# <br /> TANK I.D.# FI FT-T= I I I TT171 <br /> FORM C (6195) THIS FORM MUST BE ACCOMPANNOLAY PERMIT APPLICATION FORMS A&8 UNLESS THEY*EEN FILED PREVIOUSLY FOP035U <br /> 'W <br />