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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />-temgO, <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET l6k033 PAG N C. <br />CITY S%oA<--1ot-A COUNTY S4,rA <br />II. INSTALLATION (mark all that apply): <br />X The installer has been certified by the tank and piping manufacturers. <br />�50URCES <br />P P <br />3 O <br />W <br />• C�CiFOR N1' <br />0 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 />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 certifyon provided is true to the best of my belief and knowledge. <br />Tank Owner/A= Date C) (q8 <br />Print Name ka&zM1�� G ,o�Phone RZ,-JB4a_ qt,,36 <br />Address Ck�F— p fVt�,-),JCX S C'pl�PAI�i� <br />Po F3ox moo`-\- SA•N CZP•Mt�� CAS �`�-5533 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # �. <br />TANK I.D. # Ill <br />FORM C (7/91) THIS FORM MUST BE ACCOMPJ§ BY PERMIT APPLICATION FORMS A & B UNLESS THEY BEEN FILED PREVIOUSLY <br />