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STATE OF CALIFORNIA Eeo�n=Es <br /> STATE WATER RESOURCES CONTROL BOARD �P P oO <br /> P <br /> CERTIFICATION OF COMPLIANCE W ,it <br /> FOR UNDERGROUND STORAGE FANK'INSTALLATION of <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION/,6, re- <br /> STREET ` 7 C" x4a-our- _57—` <br /> CITY 'S70—C-kTo"L' COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> Yr The installer has been certified by the tank and piping manufacturers. <br /> N?�' 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 /> [er"'AII work listed on the manufacturer's installation checklist has been completed. <br /> V"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 inhormation provide is true to the best of my belief and knowledge. <br /> Tank Owner/Agent ' IU4M(c q; Date `/— 3`(7.5— <br /> Print Name � N,FL, Phone (.5120 <br /> Address ,!!5�6 7 G4* <br /> LOCAL AGENCY USE ONLY q� <br /> STATE COUNTY# JURISDICTION# FACILITY <br /> # TANK# /I� <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 FOR0035C7 <br />