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STATE OF CALIFORNIA fgpVNCQ3 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE Trhtlf'INSTALLATION o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET l � I 1 )!20Oki <br /> CITY S16C K c� J COUNTY SSI/-1 �56 �)UI AJ <br /> II. INSTALLATION (mark all that apply): <br /> dThe installer has been certified by the tank and piping manufacturers. <br /> d—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 /> III. OATH I certify that the information provide Is true to the best of my belief and knowledge. �^ <br /> Tank Owner/Agent d- ,1-,AE„Q.tc� coA sY,�x7o,))Date !` 3 75' <br /> Print Name ©` �lG�-� Phone (SIC ) yj7–,p4gy <br /> Address <br /> ,56 4YCAC7 - &44- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# "PACIffrn TANK# ; <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORoalsc7 <br /> 0 0 <br />