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-' <br />' STATE OF CALIFORNIA <br /> PE Sovq REg C <br /> STATE WATER RESOURCES CONTROL BOARD hr " •°i <br /> CERTIFICATION OF COMPLIANCE W ,. ' ._ ; 01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION :� <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET A/0 AT6 f: it C k f ak,- ; a as <br /> r <br /> CITY �` - Cjf <br /> 'Y W Ia COUNTY 6 6-f, <br /> II. INSTALLATION (mark all that apply): <br /> [ The installer has been certified by the tank and piping manufacturers. <br /> V'The installation has been inspected and certified by a registered professional engineer. <br /> [ T, e installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br />„Y [/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 tr7 Lestf my b knowledge. <br /> Tank Owner/Agent (ic �,( Z7, Date <br /> Print Name Q yr Phone (ZrOt -d lip Q <br /> Address c ( ltd 6 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE r� <br /> TANK I.D.# ® V U <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> t)h� <br />