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�•k,(*n�+.'nC's.++�. r'iti,aY-,w.r. _ , _ . t6' 'S. '� 'r <br /> STATE OF CALIFORNIA �5ovac6s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION d "° <br /> FORM C �,�,•oaN d <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> 9 <br /> STREET a $S"� L, F 2.L i ono S4rer't' <br /> CITY COUNTY -- - SJ96. <br /> Il. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified by a registered professional engineer. <br /> EeThe installation has been inspected and approved by the implementing agency. <br /> 4� 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 /> ❑ 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 k. fit__. Date 12..1 3 - <br /> Print Name u,c4() ,.P 1 [ i'4 <br /> ,. Phone <br /> Address �'156 7 rr:.r rZn//l Irf 5T I7( C.!''. <br /> > <br /> LOCAL AGENCY USE ONLY <br /> i <br /> STATE <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT'A Pk ICATIO.N FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br /> 4 <br />