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STATE OF CAUFDRWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 0 <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION <br /> STREET EI Ave, <br /> CITY iecok COUNTY M,u 14 <br /> 54 tJ <br /> 11. INSTALLATION(mark all that apply): <br /> F-1 The installer has been certified by the tank and piping manufacturers. <br /> F-1 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 /> ❑I All work listed on the manufacturers installation checklist has been completed. <br /> 7 The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> E] 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 �AILAJA IA/C_ �'AZ&±j k i3OAtAA1.' Phone (q <br /> Address L[Z KAWW, 42 <br /> qL <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPAPWY PERMIT APPLICATION FORMS A&B UNLESS THEYHA'16EEN FILED PREVIOUSLY FOAOM50 <br /> nw <br />