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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATI], <br />STREET <br />CITY FUCY COUNTY� <br />11. INSTALLATION (mark all that apply): <br />einstaller has been certified bythe tank and piping manufacturers. <br />�� <br />�] Theinst8||sdionh8Sbeeninop8[t8d8ndC8difiedbvanegistonedprof8SSk}n8|engin98r. <br />Z- The installation has been inspected and approved by the implementing agency. <br />Eo- All work listed on the manufacturer's installation checklist has been completed. <br />VThe installation Contractor has been certified Vrlicensed bythe Contractors State License Board. <br />E:1 Another method was used 8oallowed bythe implementing agency. (Please specify.) <br />Tank OwnefAgent <br />Print Name Akn Phone (707 ),5'q3--C*M <br />Address 0 01 95-gol <br />��- <br />STATE coum/vw .xomooICrmw# pxcILnv# TANK # / z ~°*� <br />TANK|.D. # L�l�� L-�--�--� <br />10 <br />FORM «n/9`> THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORM A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY pORommr <br />