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• • <br /> STATE OF CALIFORNIA .�'� ° <br /> STATE WATER RESOURCES CONTROL BOARD �� <br /> CERTIFICATION OF COMPLIANCE mom, <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> fj6,t r��JJ A2-063-2,-, <br /> STREET �� 2-7 DA �Ilwlell �rz-- <br /> CITY <br /> �� COUNTY <;4W b � <br /> II. INSTALLATION (mark all that apply): <br /> e installer has been certified by the tank and piping manufacturers. <br /> Ve <br /> installation has been inspected and certified by a registered professional engineer. <br /> installation has been inspected and approved by the implementing agency. <br /> ork listed on the manufacturer's installation checklist has been completed. <br /> installation Contractor has been certified and licensed by the Contractors State License Board. <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the informWdio the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name )\/r-O Phone ( ) <br /> Address v• 0)� -7/r : J X QQ J-2-i l <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (6/95) THIS FORM MUST BE ACCO ED BY PERMIT APPLICATION FORMS A&B UNLESS THIWVE BEEN FILED PREVIOUSLY FOR0035CS <br />