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• STATE OF CALIFORNIA Pt gO�"IES C <br /> STATE WATER RESOURCES CONTROL BOARD •�^ <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION <br /> STREETZ��` i=.,�1 `lc�S .,, ;t XJE. <br /> CITY Q Tr-C—A- COUNTY S1a�v 0A Q u-;-Aj <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 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 provide is true to the best of my belief and knowledge. <br /> Tank Owner/Agent __Date il f(alz00y- <br /> Print Name Phone 44 <br /> Address Co 0,P 2 —3l -L.�,t,/G� 2 CAV YOAJ 415) 3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ 17-1`1` <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c7 <br />