Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W10, <br /> �. <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET rfXSt LLMMQ✓ L-0-1010_ <br /> CITY „C , COUNTY 1�r� <br /> II. 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 r@@W4@Fed professional engineer. <br /> ✓� The installation has been inspected and approved by the implementing agency. <br /> &mor 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 /> D 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 Date S-5-cjb <br /> Print Name --y Phone <br /> Address525 L s�1hira ---*-recj dan d ('Aj q3L:tjD <br /> LOCAL AGENCY USE ONLY <br /> STATE <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# �I "1 - � <br /> Je <br /> FORM C (7/91) THIS FORM•MUST IBE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 is <br />