Laserfiche WebLink
STATE OF CALIFORNIA E OURCES <br /> STATE WATER RESOURCES CONTROL BOA Ap" •""'"' <br /> CERTIFICATION OF COMPLIANCE W . 01 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY 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 /> All work listed on the manufacturer's installation checklist has been completed. <br /> IS2�a,TThe 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 /> 111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Ownere L _ Date 1 -2,(., — G'Lp <br /> Print Name -t-- ) Phone (C)fj4p) t►—iL4 <br /> Address b'p o ' Cn. 5-1 '14 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FTI E �� <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />