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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARA <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />STREET I Z Z5" Le, <br />CITY k,2 Z2 4 COUNTY <br />11. 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 />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 />Ill. OATH I certify that the <br />Tank Owner/Agent t/ <br />Print Name L/11.1, <br />Address <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # M <br />Date J� <br />Phone ) <br />JURISDICTION # FACILITY # TANK # <br />I I I I I I I L I I I I I I <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />