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, STATE OF CAL I FORMA _ <br /> STATE WATER RESOURCES CONTROL BOARD _ <br /> CERTIFICATION OF COMPLIANCE <br /> MERGROUND STORAGE TANK INSTALL <br /> 4 <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION , <br /> STREET <br /> Smaw <br /> 441 <br /> CITY l�1�Fi�,3 .; COUNTY - <br /> 11. <br /> OUNTY II. INSTALLATION (mark all that apply): <br /> 0 The installer, pn certified by the tank and piping manufacturers <br /> The Installed v been Inspected and certified by a registered profes neer. <br /> The installatlon' as.been inspected and approved by the implementing'ak <br /> Q All work lstaemanufaturer' installation checklist has been comp <br /> s , .. � . <br /> F-� The installati66,0 ntractor has been certified or licensed by the Contractor ate License Board. <br /> 0 Another method was used as allowed by the implementing agency. (Ple �e eclfy.) <br /> Ill. OATH I certlfy that tit%information provided is true to the best of my befit knowledge. <br /> Tank Owner%Agent Date <br /> Print Name 6'z' <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ED <br /> FORM C(7iss) THIS FORM MUSTBE ACCOMPANIED$ PER IT APPLICATION FORMS A&B UNLESS THEY HA E,BEEN FILED PREVIOUSLY FOR��7 <br /> y� <br />