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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE d� <br /> n� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION :s <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> � \ l <br /> STREET <br /> CITY%�" i,A cA COUNTY <br /> II. INSTALL ON (mark all that apply): <br /> he 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 /> it AllWork listed on the manufacturer's installation checklist has been completed. <br /> � The installation Contractor has been certified and licensed b <br /> Y the Contractors State License Board. <br /> C' Another method was used as allowed by the implementing agency. (Please specify.) <br /> i <br /> 111. OATH I certify that the or, n provided is true t the best of my belief and knowledge. <br /> Tank Owner/Agent Date <br /> o /J�►�' 1; J Phone <br /> Print Name (���' ) R _ "' <br /> Address 7/ <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C8 <br /> f <br />