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§ J � <br /> TIT <br /> STATE OF CALIFORNIA > 1 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> fix..,.,.. i, <br /> CERTIFICATION OF COMPLIANCE 3 ° <br /> g " FOR UNDERGROUND STORAGE TANK INSTALLATION rs o <br /> FORM C <br /> ! <br /> COMPLETE A SEPARATE FORM FOR EACH-TANK SYSTEM <br /> ! <br /> I. SITE LOCATION <br /> r 4 <br /> a� <br /> STREETC ( . . <br /> I <br /> CIT E "r` COUNTY <br /> i <br /> u <br /> x <br /> II. INSTALLATION(mafkll thiatapply): <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 /> E] All work listed on the manufacturer's installation checklist has been completed. <br /> 4(g.. ❑ The installation Contractor.has been certified or licensed by the Contractors State License Board. � <br /> ❑ Another rrrethod was used as allowed by the implementing agency. (Please specify.) <br /> t : <br /> s <br /> III.BATH I certify that the information provided is true to the best 'of my belief and knoWjedge. <br />{ <br /> kTank Owher/Agent Date . <br /> Print Name Phone. ( ) <br /> �f <br /> Address <br /> LOCAL AQFI NCY,USE ONLY I <br /> hF M <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ru FM <br /> I. g <br /> FORM C 7/91 <br /> S FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br /> 3 y <br /> f <br />