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0 STATE OF CAUFORMA 5o ACEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION . ........... <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION of �Tbp --* 3 1 <br /> STREET c2,2 9)5- E, F-12-r-- t—Ai2VIT <br /> CITY 154ve-L±C, //V <br /> COUNTY <br /> 11. INSTALLATION (mark all that apply): <br /> ZThe 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 /> 5?� The installation has been inspected and approved by the implementing agency. <br /> OZ All work listed on the manufacturer's installation checklist has been completed. <br /> EZ' The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> F7 Another method was used as allowed by the implementing agency. (Please specify.) <br /> I1111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent 11 Date <br /> Print Name f2 <br /> ,4,V V�n Phone (,$10 CS- <br /> Address 4156 7 gn-FS&A/i X-C 47, &Sowon!r� CA- <br /> 5 74,A� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILrFY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br /> 9 9 <br />