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STATE OF CALIFORNIA ESpUACES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 9 <br /> CERTIFICATION OF COMPLIANCE W y <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C C• ,cppN,�. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION14, <br /> // _/ <br /> STREET �4Y' �so/ �— ac K TOGt_c_ Taos <br /> b <br /> CITY ot1 COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> 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 /> �he installation Contractor has been certified or licensed by the Contractors State License Board. <br /> O Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the information provided is true t st of my be ' nowledge. <br /> Tank Owner/Agent /4lKcf I , Gcc Date /YDS <br /> Print Name c p �w�t�e Phone OD I ) 7�3W.--6 4162) <br /> Address5b W e�-�, �1Sj 6 5-o u--&, l^� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 3T9-1 L151 d 5L4 ILT 01 <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 is <br />