Laserfiche WebLink
-W <br /> • STATE OF CALIFORNIA • E5°uwcES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> P <br /> CERTIFICATION OF COMPLIANCE W ,� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION r� <br /> FORM C "`"`ti"" <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION 63? <br /> STREET [Vest <br /> CITY—&"10 COUNTY Ltr <br /> 11. 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 provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent` � + 1 ; _ Date <br /> Print Name , Phone 0 <br /> Address (�eS S "'� `(6c6p, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ I I <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />