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<. <br /> i .. :: <br /> STATE OF CALIFORNIA rESOvp°ES C <br /> STATE WATER RESOURCES CONTROL BOARD Ae <br /> 9 <br /> CERTIFICATION OF COMPLIANCE Q <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C �4l pORN P <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 740 1;�110 <br /> CITY j bo-K. _ I W'^t`COUNTY SEs�—gw�, © G�t.•+M-- <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 /> Z The installation has been inspected and approved by the implementing agency. <br /> I 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 /> 111. OATH I certify that the information provided is true to st of my bell owledge. <br /> Tank Owner/Agent ! Ltc,, to <br /> Print Name Y'l�tC +� Phone ) ) / <br /> Address + u3 e.S� O c- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ® . oz <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />