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INSTRUCTIONS FOR COMPLETING FORM "C` TANK INSTALLATION CERTIFICATION <br /> This farm is required for piping replacements, but not piping repairs. <br /> GENERAL INSTRUCTIONS <br /> 1. Each tank system must be in compliance with the fr;deral and state technical standards, <br /> contained in law and regulations, for tank and piping installation, <br /> 2. This certification shall be completed by either the UST owner or representative. <br /> . One certification is required for each tank system, This form shall be used to make the <br /> required certification. <br /> 4. Please type or print clearly all requested information (for printing, please us a.bard paint <br /> writing instrument). <br /> Submit the completed certification to the appropriate Local Implementing Agency. <br /> !. <br /> INSTALLATION- MARK .ALL OF THE ITEMS THAT APPLY TO INDICATE T1--:AT THE <br /> INSTALLATION REQUIREMENTS TS ARE MET. <br /> ll. OATH. THE TANK OWNER OR AGENT SHALL. CERTIFY, BY SIGNING THE CERTIFICATIONS <br /> THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. THE PERSON'S <br /> NAME SHOULD BE PRINTED CINDER THE SIGNATURE. <br /> . <br /> INSTRUCTION FOR THE LOCAL. AGENCIES <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the <br /> State Sward (91 6) 227-4301 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 State Board to assign the facility number, please leave it blank. <br /> It is the responsibility of the local agency that inspects the facility to veru 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 /> ,K} t <br />