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9 STATE OF CALIFORNIA - .`go �. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3` <br /> FOR UN RGROUND STORAGE TANK INSTALL ATIQ <br /> FORM C '�¢ <br /> rY gg <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREETy <br /> CITY COUNTY S' ® T_J�,� <br /> II. INSTALLATION (mark all that apply): <br /> 0 The installer,q s eep certified by the tank and piping manufacturers::.. -T ; T <br /> The Instahatlo e n inspected and certified by a registered�professlonA sneer. <br /> , . <br /> The installation'hfi t3een inspected and approved by the implementing agency r , <br /> All work listed,p'" <br /> F-1 �,�anufacturer'sinstallation checklist has been completed . ..'. <br /> 0 The instal latibt',Pgntractor has been certified or licensed by the Contractors Slate License Board. <br /> O Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that t ipinformation 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 p191> THIS FORM MU& .BIRA000MPANIED BY PERMIT APPLICATION FORMS d&B UNLESS THEY NAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> R <br /> 3 <br /> t^ <br /> x <br /> q <br />