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rax x <br />1 740 <br />s, �" <br />b" 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 />I. SITE LOCATION <br />STREET �j d.�� OK4.. dac <br />CITY I ok CQ, COUNTYat� �t t <br />H. INSTALLATION (mark all that apply): �. <br />The installer has been certified by the tank and piping manufacturers. <br />�The <br />he installation has been inspected and certified by a registered professional engineer. <br />installation has been -inspected and approved by the implementing agency. <br />/All 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 />❑ Another method was used as allowed,by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the <br />Tank Owner/Agent M ,,..i <br />Print Namey u Cu fley <br />Address SCS k'Jes7-, ?p` SO cl"5Y� <br />LOCAL AGENCY USE ONLY <br />my beliefwiedge. <br />ahon/e,/,, ) dd <br />nil k & ki Com( %� I � <br />STATE COUNTY # <br />JURISDICTION # . <br />: # <br />TANK # <br />TANK I.D. # <br />nnFACILITY <br />+✓ <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />