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0 0 <br /> INSTRUCTIONS FOR COMPLETING FORM "C` TANK INSTALLATION CERTIFICATION <br /> This form is required for piping replacements, but not piping repairs. <br /> GENERAL INSTRUCTIONS <br /> 1, Each tank system must be in compliance with the federal and state technical standards, <br /> contained in law and regulations, for tank and piping installation, <br /> This certification shall be completed by either tete LIST owner or representative, <br /> One certification is required for each tank system, This fora,shall be used to make the <br /> required certification. <br /> 4. Please type or print clearly all requested information (for printing, please use a harts point <br /> writing instrument), <br /> 5. Submit the completed certification to the appropriate Local Implementing Agency. <br /> [. INSTALLATION: MARK ALL OF THE ITEMS THAT APPLE TO INDICATE 7-'-!AT THE <br /> INSTALLATION REQUIREMENTS ARE MET. <br /> If. OATH; THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING TIME CERTIFICATION, <br /> THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. THE PERSON'S <br /> GAME SHOULD BE PRINTED UNSER TL E 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 (916) 227"-4302. The facility number may be assigned by the local agency; <br /> however, this number must be numerical and cannot contain any alphabetical characters. <br /> If the local agency prefers the Mate Board to assign the facility number, please leave it blank. �. <br /> It is the responsibility of the local agency that inspects tete facility to verify the accuracy of the <br /> information. The local agency is responsible for the completion of the "local agency use only" <br /> information box. The local agency should retain the original and yellow copies, The pink <br /> copy should be retained by the tank owner. <br />