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• STATE OF CALIFORNIA f gpV ACEs <br /> STATE WATER RESOURCES CONTROL BOARD • �P P p°� <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET u �b vim-- & L.Ja <br /> CITY �a COUNTY l�J. <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.) N [PC <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent r—i(hJCtZ C us,-r L(,)C. Date $''13"fig <br /> Print Name `�q0y 4 na*Qa wa Phone <br /> Address 5633 5 Wce-r V o o <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ 6 �51016-14� <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 />