Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD .° <br /> CERTIFICATION OF COMPLIANCE w <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION rs o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET C>LK AS6 c�Lc-fG]!'Uhf o�� <br /> CITY � � � tzr 00NTY <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 /> [' ] <br /> Ark 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 /> E:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information provided is true to of my belief owledge. <br /> Tank Owner/Agent _ ate �? 1 4 <br /> Print Name„a� ��,� hone a� ) �� 6 b b <br /> Address �—gD Ly �s!- �1 O 5. <br /> Li <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 1 6 <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 9 0 <br />