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STATE OF CALIFORNIA ESo�Rces <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE ` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> • °�CIfOR N.f <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION Cavi k- ST o P �* 31 <br /> STREET QQ A S" L , r-Cz 1', m6v,T '-.,4r er+ <br /> CITY COUNTY C�Y1 `Tya Grc�i in <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> L ❑ 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 /> I <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> j 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 /> I <br /> i <br /> i <br /> j <br /> I <br /> 111111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent � �� _. Date/2-2 <br /> Print Name Phone <br /> f _ <br /> Address /5 '/ /I/✓�!'i/�iI�rV ST /'z,�. �,� G-4 <br /> f4 rx, <br />' LOCAL AGENCY USE ONLY <br /> I COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE ❑��j�� <br /> TANK I.D.# ❑ 1 FTI I I 1 1 I <br /> FORM C (7i91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br /> 0 01 <br /> ti <br />