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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 <br />CITY COUNTY 5;1'* ✓� <br />II. INSTALLATION (mark all that apply): <br />V 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 />All work listed on the manufacturer's installation checklist has been completed. <br />j The installation Contractor has been certified or licensed by the Contractors State License Board. <br />C Another method was used as allowed by the implementing agency. (Please specify.) <br />III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Ownr/AgW �,w�e s Date <br />Print Name 2r Phone (s -r9> yyy_i73a <br />Address Sod 7 AlPA <br />rA-70,, 93 726 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑ Ll I I FF I I I I I L I I� <br />F0RM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0075C7 <br />