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STATE OF CALIFORNIA As <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION <br /> STREET <br /> CITY4 21 <br /> COUNTY <br /> 11. INSTALLATION (mark all that apply): <br /> V--1,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 informatio rovided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent &4t, Date //2,19 7 <br /> 7" �7 <br /> Print Name Aoo. Phone (.2o 91 ) <br /> Address 242a <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# E= T-F� <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORD035C7 <br />