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0 STATE OF CALIFORNIA esov"Oea <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W� _ <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET — VQY`lk A50I 4-C,14' -O wz WO aX `- <br /> CITY l Cd- ► NTY �� u <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 /> zZThe installation has been inspected and approved by the implementing agency. <br /> I work 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 /> Ill. OATH I certify that the information provided is t the best of m and knowledge. <br /> Tank Owner/Agent ► ja-c cr Date <br /> Print Name c co ,4t, Phone <br /> Address LCJ e z< c er <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I ozol15tol,�- 91G IL <br /> FORM c I7r91l THIS F M MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035c7 <br />