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• STATE OF CALIFORNIA • Eeo�"`.s <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 &AAIl�Ii C(� 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 />F?� The installation has been inspected and approved by the implementing agency. <br />[PI/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 />El 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 <br />Print Name <br />LOCAL AGENCY USE ONLY <br />STATECOUNTY# <br />TANK I.D. # IaY <br />Date —1 .to <br />`Z <br />Phone (TO -7) 745 —"1 <br />4a/600 <br />JURISDICTION# FACILITY# TANK# a�A% <br />FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICAI IUN YUNMS A& M uMLtss I MLT MAvc M=N riLcu rncvluwu <br />0 q-1 it - I �? X�,� 0 <br />