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STATE OF CALIFORNIA Ee- Acea <br /> STATE WATER RESOURCES CONTROL BOARD <br /> A <br /> CERTIFICATION OF COMPLIANCE W ;t <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET V`CTot- tookJ <br /> CITY LoL COUNTY A� v t` <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 registered professional engineer. <br /> F<1 The installation has been inspected and approved by the implementing agency. <br /> 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent l ! Co /j EjT U ft-) Date <br /> In f <br /> Print Name \ Lsj"c.,jPhone ( /6 ) qq7- 2,qqq <br /> Address S(,,-1 A#j6E- C-17- L, -C4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ ❑_ 1 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />