Laserfiche WebLink
• STATE OF CALIFORNIA E5°V^meg <br /> STATE WATER RESOURCES CONTROL BOARD • Ae" '"" °°r <br /> CERTIFICATION OF COMPLIANCE W �, �°, <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s . o' <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET CN <br /> j�30 T -RaWAAA <br /> CITY COUNTY <br /> H. 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 /> [P The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> D Another method was used as allowed by the implementing agency. (Please specify.) 9 <br /> /4- <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent f lN aelt 605T. V1 C Date <br /> Print Name <br /> . <br /> 'C'7t8Y SCffRO£OEn Phone <br /> Address 3633 SEAArT $/✓o -`/rot <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# LL I I I <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 6 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />