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STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD c 1r <br /> CERTIFICATION OF COMPLIANCE <br /> no <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION o <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY pal �?��1— COUNTY L-n < J'�r ("V, <br /> II. INSTALLA ON (mark all that apply): <br /> e installer has been certified by the tank and piping manufacturers. <br /> j�_ The installation has been inspected and certified by a registered professional engineer. <br /> he installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturerPs installation checklist has been completed. <br /> The installation Contractor has been certified and licensed by the Contractors State License Board. <br /> C Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the info; nrovil s true to the best of my belief and knowledge. } <br /> J L <br /> Tank Owner/Agent t Date 1 / <br /> Print Name _ 11\44,�- Phone <br /> Address 0 . / c> <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 />