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INSTRUCTIONS FOR COMPLETING FORM "C": TANK INSTALLATION CERTIFICATION <br /> This form is required for piping nepkaoements, but not piping repairs. <br /> GENERAL INSTRUCTIONS <br /> 1. Each tank system must beincompliance with the federal and state technical standards, <br /> contained in |avv and neQu|ationo, for tank and piping installation. <br /> - <br /> 2. This certification shall be completed by either the LIST owner or representative. <br /> 3. One certification iarequired for each tank system. This form shall beused tomake the <br /> required certification. <br /> 4. Please type orprint clearly aUmaquesh&tiafofm&1ion (for pdntLng. please use sdhardpoint <br /> writing instrument). <br /> ^ ' <br /> 5. Gubnn | the <br /> - - -etedce ' Ocedionb)the appropriate Local |mp|ern-e6tihgAgen-c� <br /> i INSTALLATION: MARK ALL OF THE ITEMS THAT APPLY TO INDICATE THAT THE <br /> INSTALLATION REQUIREMENTS ARE MET. <br /> ||. OATH: THE TANK OWNER OR AGENT SHALL CEBT|FY, BY SIGNING THE CERTIFICATION, <br /> THAT THE |NF{lRK8AT|[}N PROVIDED IS TRUE AND CORRECT. THE PERSON'S <br /> NAME SHOULD BE PRINTED UNDER THE SIGNATURE. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the _. . <br /> State Board kB16\ 227-4383. The facility number may Ue assigned twthe local agency; <br /> however, this number must be numerical and cannot contain any alphabetical characters. <br /> If the local agency prefers the State Board to assign the facility number, please leave it blank. .' <br /> ' <br /> It is the responsibility of the local agency that inspects the facility to verify the accuracy of the <br /> information. The local agency|sresponsible for the completion ofthe "local agency use only" <br /> information box. The local agency should retain the original and yellow copies. The pink <br /> copy should beretained bythe tank owner. <br /> - ^` — - - <br /> ` <br /> - <br />� <br />� U <br />^ n <br />