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STWE OF CAUSHKA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICAMN OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COM PLM A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1.SITE LOCATION <br /> STREET <br /> CITY 65 CA 6 e>J 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 /> le' -the installation has been inspected and approved by the implementing agency- <br /> F-3 �11 work listed on the mEkwfacturer's installation checklist has been completed. <br /> I-A-<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 inform n provided is true to the best of my belief and Im,owledge. <br /> Tank Owne ......D ate-- <br /> Print Name Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> S747C COUNTY JURISDICTION 4 FACILITY 9 TANK 4 <br /> TANK 1.0.# <br /> FORM C (7191) THS FORM MUST B9 ANNE BY PERMT APPLICATION FORMS A&8 UNLESSTHEY HAVE MEN Fu0puVIOUSLY F <br /> `cigo L eLLZ;6W dVISISEIM/dVIS-171V "Od-i HVVS:6 866L-8t-6 <br />