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s`• ,� -L .. ".}Yx:C.L.. -. }.y5- '+Wx�._.. _ ..- ,.�a 2e 4" �^. <br /> x <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD .P. 0 <br /> p <br /> CERTIFICATION OF COMPLIANCE 3 ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION rs o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET b V�7�li.. f�� / cJ Ate = >Oexcv <br /> CITY 4 SAL. u -'0k000NTY _:5 ► �dRta e.w� <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> Z-(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 /> j A ork 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 of my belief owledge. <br /> Tank Owner/Agent Gc. _ ate a? 19'st <br /> Print Name �,, � � � hone ) —6 D d <br /> Address ! !.V +rs �6 -- y^ lkaA oll <br /> � �a <br /> i <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITYY# TANK# <br /> TANK I.D.# AL516161 ;QG <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />