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STATE OF CALIFORNIA ego ,SEs <br /> STATE WATER RESOURCES CONTROL BOARD A r <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I.SITE LOCATION 4e-C) �Ck <br /> STREET aAD b �rk,26 1A N1 <br /> CITY TD-C COUNTY _ LA \ cSoA�V <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 /> 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 101 k3 <br /> Print Name Phone (11 610.S�o y <br /> Address ra 0 P® • b03'$ P1� �blOa,- 1ov3 $ <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ ❑_❑ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPAN D BY PERMIT APPLICATION FORMS A&8 UNLESS THEY H VE BEEN FILED PREVIOUSLY FOR0035C7 <br />