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STATE OF CALIFORNIA • ��SpV °f S c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION a <br /> .i <br /> FORM C C�l,ipp„•. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION allitc- STOP �2¢ <br /> STREET So'S N• MAlfu 5Z2c T <br /> CITY MA-,JCe;LPr COUNTY 5A-..l <br /> II. INSTALLATION (mark all that apply): <br /> [ The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> O 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 Owner/Agent Date <br /> Print Name Phone ( ) <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMP#BY PERMIT APPLICATION FORMS A&B UNLESS THEY 6 <br /> BEEN FILED PREVIOUSLY <br />