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r STATE OF CALIFORNIA E sovacea <br /> STATE WATER RESOURCES CONTROL BOARD APP •"" A <br /> CERTIFICATION OF COMPLIANCE W <br /> r �u <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION CCS l f l <br /> f <br /> STREET Ok do— <br /> CITY <br /> CITY COUNTY k 06? r <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> F-� 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 /> E] 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 ( C CO Date <br /> Print Name <br /> l e r��-2_ `t® ki I Phone (3f® ) a2(46j' <br /> Address <br /> I <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 511 <br /> FORM c (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEENFILEDFILED PREVIOUSLY FOR0035C7 <br /> i _ —q,3 47n <br />