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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET Inln33 5` -C -\E \ C- AVe-rA\JE <br />CITY COUNTY SAt,1 JQAQQItA <br />II. INSTALLATION (mark all that apply): <br />)411 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 />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/Age - Date 04A3 hg <br />Print Name NEp„-rE� G k ��-�-�� Phone (CtZS) <br />AddressCN�� Q(�pt�G"C� C-JI�r�P�.t�:� <br />Po E.� x eco©'- SAA Rob -t c)rA CA <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # / <br />TANK I.D. # m',� Y10 <br />FORM C (7/91) THIS FORM MUST BE ACCOMP�D BY PERMIT APPLICATION FORMS A & B UNLESS THEY�E BEEN FILED PREVIOUSLY <br />