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STATE OF CALIFORNIA • ESpVACES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s o' <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET �Olrtl� Jed J ctc 7�or2� o« <br /> CITY > `ok -yk ld COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> /The installer has been certified by the tank and piping manufacturers. <br /> 7Ve installation has been inspected and certified by a registered professional engineer. <br /> The installation has been inspected and approved by the implementing agency. <br /> ]�Al work listed on the manufacturer's installation checklist has been completed. <br /> 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 /> Ill. OATH I certify that the information provided is true to the best—Df my belief Wedge. <br /> I C/� <br /> Tank Owner/Agent /n e <br /> Print Name L,—e�, hone <br /> Address �& <br /> 57 36� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# M D LItA b <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 011 0 <br />