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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W a <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s os <br /> FORM C <br /> • ��Cif pR N.P. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION TF-Ac-`t 5Zof' <br /> STREET '39 �� <br /> CITY `C Y COUNTY 5A-' 3oR-0.yl�J <br /> II. INSTALLATION (mark all that apply): <br /> '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 /> The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Ag !� Date 0A h z;� <br /> Print Nam �L ��� Phone (//l ) ��7�—/j'�� <br /> Address 1-3 0,A19020, r,9 <br /> LOCAL AGENCY USE ONLY ��yy <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F-F] J r -7 19 3 -7 S <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />