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• STATE OF CALIFORNIA Iq <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 />❑ 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.) <br />Ill. 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 Phone ( ) <br />Address <br />LOCAL AGENCY USE ONLY <br />STATECOUTTNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # W <br />FORM C pisil THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A S B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROM5C7 <br />