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I. SITE LOCATION <br />STATE OF CALIFORNIA • <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />STREET Y'7k /SOS Macipkx. � oadd <br />CITYoK rKta. .� COUNTY c�e�u 00. t,ttit,t <br />II. INSTALLATION (mark all that apply): <br />9 , `: # "J-71 <br />` <br />k <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 />The installation has been inspected and approved by the implementing agency. <br />All work listed on the manufacturer's installation checklist has been completed. <br />MxThe installation Contractor has been certified or licensed bythe Contractors State License Board. <br />C� Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the information provided is true t st of my be ' nowledge. <br />Tank Owner/Agent /yt t u ate <br />Print Name , y u w-��t, yt Phone (� �) �,-3, -6V60 <br />Address cid Wes1.0 t3 _Socam - Y!I q7" <br />45-V <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 3T91 IBJ 1 01 7I <br />FORM c hisil THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />el <br />• <br />FOR0035C7 A <br />X <br />;,FW <br />I. SITE LOCATION <br />STATE OF CALIFORNIA • <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />STREET Y'7k /SOS Macipkx. � oadd <br />CITYoK rKta. .� COUNTY c�e�u 00. t,ttit,t <br />II. INSTALLATION (mark all that apply): <br />9 , `: # "J-71 <br />` <br />k <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 />The installation has been inspected and approved by the implementing agency. <br />All work listed on the manufacturer's installation checklist has been completed. <br />MxThe installation Contractor has been certified or licensed bythe Contractors State License Board. <br />C� Another method was used as allowed by the implementing agency. (Please specify.) <br />111. OATH I certify that the information provided is true t st of my be ' nowledge. <br />Tank Owner/Agent /yt t u ate <br />Print Name , y u w-��t, yt Phone (� �) �,-3, -6V60 <br />Address cid Wes1.0 t3 _Socam - Y!I q7" <br />45-V <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 3T91 IBJ 1 01 7I <br />FORM c hisil THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />el <br />• <br />FOR0035C7 A <br />X <br />