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IV ` STATE OF CALIFORNIA 5o ACES <br /> Iy STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE- <br /> F ilk,u <br /> {, FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> r^ , <br /> STREET <br /> CITY t^ �� COUNTY <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 /> 0 All work listed on the manufacturer's installation checklist has been completed. <br /> r.- <br /> ❑ The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> ❑ 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 /> I <br /> a <br /> Tank Owner/Agent Date <br /> i <br /> Print Name Phone ( ) <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> STATE � TANK# <br /> TANK I.D.# ��❑ �I I, <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> f <br /> 1 . <br />