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• STATE OFCALIFORMA • fyo�R�es <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 9 <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> • C�[IfOR N.� <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION �r <br /> STREET0r <br /> F <br /> CITYCa//' Avilld, COUNTY VA kt 60. a/14 <br /> II. INSTALLATION (mark all that apply): <br /> /,"The installer has been certified by the tank and piping manufacturers. <br /> [r] 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 /> ��The <br /> II work listed on the manufacturer's installation checklist has been completed. <br /> 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 /> 111. OATH I certify that In tion provided ' e to the b t of my belief and knowledge. <br /> Tank Owner/Agent /if J, it—Ac , Date N <br /> Print Name r U �Ll �, Phone (8L elw U <br /> Address Sd Gc,es7C, g�l� Sm 1?k-y1 afA4 Cr: <br /> i/ b <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 31kU O 5 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORD035C7 <br />