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STATE OF CALIFORNIA f5pV"cES <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W � ,�01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION / <br /> STREET /Y O r �c5d / jQ c K 16Xe_ �f a ax <br /> r <br /> CITY ` o� � ' o ^k r COUNTY 6 a w <br /> II. INSTALLATION (mark all that apply): <br /> YThe installer has been certified by the tank and piping manufacturers. <br /> CV"'The installation has been inspected and certified by a registered professional engineer. <br /> Pe installation has been inspected and approved by the implementing agency. <br /> All 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 /> III. OATH I certify that the information provided is true est of myb knowledge. <br /> Tank Owner/Agent ��t,���c 4 � � Date <br /> Print Name c. pip' Phone (861 ) p <br /> Address W T Q <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# 311 <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 />