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• STATE OF CALIFORNIA • gOVACES <br /> STATE WATER RESOURCES CONTROL BOARD AP PE <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION rs o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION TPP'`C'/ TQ I Gbc 4 A07'0 5zo'P <br /> STREET 5 1 Ltd N [ �E <br /> CITY QAc�/ COUNTY Siad <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 /> D 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 /> D 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/Age Date <br /> Print Name ¢�� Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY#77 TANK# 00 <br /> TANK I.D.# FT-1 Q <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />