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rVnIV1 k. <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET f urlm Ap ul iQGKTaYTe Tioaey , <br />CITY COUNTY \SQ yL-Qaltlfit <br />II. INSTALLATION (mark all that apply): <br />/The installer has been certified by the tank and piping manufacturers. <br />j The installation has been inspected and certified by a registered professional engineer. <br />C1%] The installation has been inspected and approved by the implementing agency. <br />VT <br />II work listed on the manufacturer's installation checklist has been completed. <br />he installation Contractor has been certified or licensed by the Contractors State License Board. <br />1:J Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that <br />Tank Owner/Agent <br />Print Name <br />Address �d <br />provide 1p to the 7bst of my belief and knowledge. <br />/ /1/141 J� �LUc , Date KI0 P-1 19y,5 <br />Phone <br />2 - <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. #✓I / 115W 1d <br />FORM c (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />