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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD .� <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a v, <br /> FORM C <br /> • C�[l.pq Nq <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION P0.wGc �03�^1 <br /> STREET aa�d Crr ► GNZ <br /> CITY `c�-C COUNTY SQ� jac4c,V <br /> If. 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 /> A- 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 /> -C <br /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> Print Name y Phone (-il� <br /> Address ro 0 PO • b03•$ CIP11,C, �fll0a- lod3 <br /> s <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 ACCOMPA D BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br />