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STATE OFCALIFOFNA eovRlea <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 0 <br /> CERTIFICATION OF COMPLIANCE I <br /> cop <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Ovilc- 6701" 41F3C( <br /> STREET 2-2 1—® E P— 1-- rn 0 01 �-+Lcr+ <br /> CITY cIG COUNTY iSAO Vc'eL-quin <br /> Ill. INSTALLATION (mark all that apply): <br /> 5K The installer has been certified by the tank and piping manufacturers. <br /> F-1 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 &-)ZDate 12-4-3—'76 <br /> Print Name Phone <br /> Address CA- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# F17 I I I I I I I I I I I I I I <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />