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• STATE OF CALIFORNIA a� s <br /> �E aaa4. C <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W w ! <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a <br /> FORM C C•[IFORN'. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Ti2ACy -r P-UC k-' Y � -r� SCc P <br /> STREET g �� N L 314V <br /> CITY T'QAC-Y COUNTY 5A"j 2.0"""-o j <br /> II. INSTALLATION (mark all that apply): <br /> ,2�[- 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 /> 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 /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> 11111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Ag Date4,",,!? <br /> Print Name o / Phone )32)_��� <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 1771 d <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />