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• STATE OF CALIFORNIA Eso�A�Es <br /> STATE WATER RESOURCES CONTROL BOARD • Ac r '" �� <br /> CERTIFICATION OF COMPLIANCE 3�, <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION kkco liGC 63q-1 <br /> STREET aAD a (2:'rctlPt-3 <br /> CITY c C COUNTY ZQ,r\ jpc,c, <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 /> j 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 /> E] Another method was used as allowed by the implementing agency. (Please specify.) <br /> UST SST i �w.c�vC��n <br /> <c cx� �� ��► <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 101�k <br /> Print Name Phone (-),� ) 6'10 <br /> Address �n �ro 40ft -S <br /> �v <br /> Ps i c. t7-)D a, loy 3 8 t <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ ❑ I � <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 />