Laserfiche WebLink
STATE OF CALIFORNIA • .. <br /> STATE WATER RESOURCES CONTROL BOARD PE SOJ n�ES <br /> CERTIFICATION OF COMPLIANCE 3 , <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 1-2-3`t ��s `�oS- � A✓E� <br /> CITY M A0f�=C._., COUNTY SANS Q0jkaLLtQkj <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 /> II 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 4:)� Date 1 ( lu l 2-401 <br /> Print Name G'Lu F- E-y I/o6 a. Phone (%ZS-) <br /> Address (o O40 2 CAVY It1 Rc)ej a s,��1 ,qi� t/ C-4. C1 , Ss3 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FT-1 I I El= <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br />