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STATE OF CALIFORNIA s.0"1, <br /> STATE WATER RESOURCES CONTROL BOARD w�Pf `°" <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION w o� <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET !]a sfi u <br /> CITY ��I(X To N COUNTY :54 N Jog Qv,' '-J <br /> II. INSTALLATION (mark all that apply): <br /> ❑wThe 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 ( 1 <br /> Address <br /> LOCAL AGENCY USE ONLY <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 PREVIOUSLY FOR0075C7 <br />