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STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD P`E5•""Rqs 00% <br /> CERTIFICATION MPLI C ° <br /> F T KINSTALLATION <br /> �A <br /> • C4(sow NSP <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET r <br /> L <br /> CIT <br /> II. INSTALLATION (mark all that apply): <br /> ❑ 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 /> F-] The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> E:1 Another method Was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information pr vi is truebelief ledge. <br /> TankOwner/Agent Date <br /> Print Name Phone ( ) <br /> Address <br /> LCL AGENCY L <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# (� <br /> TANK I.D.# ❑ �� I <br /> FORM C (7/si} THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORKS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br /> 0 <br />,. J <br />