Laserfiche WebLink
STATE OF CALIFORNIA * ESpVaCEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W u01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET �Uo vf L ISO / /�c 7��►1-e, a <br /> CITY " COUNTY �o Ucnti— <br /> II. INSTALLATION (mark all that apply): <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 /> l:�( I work listed on the manufacturer's installation checklist has been completed. <br /> ;'/� <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 /> 111. OATH I certify that the information provided is true ton-,O,�, <br /> my beli oWedge. <br /> r-- <br /> Tank Owner/Agent 1 v u tam, <br /> Print Name y,u� �-� Phone S n) ) 3Y --6 4o <br /> Address es5� Q 5.0 <br /> Fsf.�a�-- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ® ® :51 d 05 qq <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />