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STATE OF CALIFORNIA A s <br /> STATE WATER RESOURCES CONTROL BOARD AP"f s° <br /> CERTIFICATION OF COMPLIANCE W ,� <br /> FOR UNDERGROUND STORAGE TAWNSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET M 17 ?5Q MDti'7- -` 7l <br /> CITY �� ���ti COUNTY <br /> Il. INSTALLATION (mark all that apply): <br /> The 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 /> E�1/The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 0 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the inf9rmatiopprovi5od is true to the best of my belief and knowledge. cy <br /> Tank Owner/AgentC3-L �Ic�M- C 1A�yT�jov Date L�"3—[0 <br /> Print NameJe) , Phone (�$ ) ��%•ay <br /> Address S47 C jr-4*--,Ge- C,7-- L,1 v444W-o!5:7 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I O <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />