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.e..r•e •ar r , ZL49u`® $10 Jul IOZZIN 1 <br /> r <br /> VATt OF UMMA <br /> STATE WATER RESOUR(;ES COMOL ROARO <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 :5 7-6 3Q� <br /> STREETt� <br /> CITY�1®v-t J ®F Tit COUNTY iA/ gv r <br /> 11. INSTALLATION(mark all that apply); <br /> Zi-he installer has been certified by the tank and piping manufacturers. <br /> The installation has been inspected and certified by a registered professional engineer. <br /> '?r The installation has been inspected and approved by the implementind agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> The installation Contractor has been certified or ltaensed by the Contractors State License rd. <br /> Another method was used as allowed by the implementing agency. (please specify.) <br /> / L. .�• �. ` <br /> Al. <br /> C � <br /> III.OATH I certify that the informatlon rovided is V `�Sl <br /> P e to Ytte s f my t' I n knowled e. 01, <br /> 9 <br /> Tank owrner/AgentA totsI- od �iG., =He— Date Q� ®�9 <br /> Print(Name E7A, <br /> Phonep s <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE: COUNTY A JURISDICTION s Ftp ry t T <br /> AM <br /> TANK I.D.a► I—L—L <br /> r <br /> FORM c 17.111 THIS FORM MUST BE ACCOMPANIED BY PERINT APPLUTON FORMS A i 8 UNLES3 TM HAYS BEEN FRED PREYIouftYFORo= <br />