Laserfiche WebLink
STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <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 <br />STREET <br />CITY % COUNTY <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 />0 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 />III. 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 %,����`- �� 51ZPhone (,"a <br />Address �`�l% �/� !!:�� /g <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ <br />111FU 11111H <br />FUHM U (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />