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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 x701 ,? 5 T C n� r to r W a ,/ <br />CITY 4A 7U N COUNTY sI? ti) Lr 6tvJJ <br />II. INSTALLATION (mark all that apply): <br />V11 -The installer has been certified by the tank and piping manufacturers. <br />71 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 />111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/ <br />Print Name <br />Address <br />LOCAL AGENCY USE ONLY <br />Date <br />Phone ( <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PHEVIOUSLY FOR0035G7 <br />