Laserfiche WebLink
STATE OF CALIFORNIA aESou" Esc <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE -° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION =� <br /> FORM C „VT� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET ��� I �dl M ►] �'i�-�` <br /> CITY COUNTY -e <br /> 11. INSTALLATION (mark all that apply): <br /> 0 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 /> El Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. 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 /> STATE {COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# I I <br /> FC)FIM c (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />