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FISIOW"o <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />705? <br />IWWNA�l Mo� <br />CITY Z,509 Z&/(/ COUNTY -5421/ e111 V <br />11. INSTALLATION (mark all that apply): <br />0 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 />F--1 All work listed on the manufacturer's installation checklist has been completed. <br />>q- 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 />Tank Owner/ <br />Print Name <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # FTI <br />III J 111 iiiiiiJ�ll� Jill I 111 1111111 11 11111 1; 111111111 !! 111111 1 1 1 1 1 1 1 11 111111 11 1 1 11111111 <br />Date Z/— <br />'6,hone (2:Al 1-mc-ijiJ zzz <br />0 <br />JURISDICTION # FACILITY # TANK # <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035IG7 <br />