Laserfiche WebLink
STATE OF CALIFORNIA aESOUR°Ae° <br /> STATE WATER RESOURCES CONTROL BOARD ha <br /> TI F COMPLIANCE <br /> 3 e <br /> STORAGEFOR UNDERGROUND INSTALLATIONFORM C <br /> r� 's <br /> • Cil/FOW NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET l m <br /> CITYCOUNTY <br /> II. 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 /> The installation has been inspected and approved by the implementing agency. <br /> II 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 /> III. OATH I certify that the infrprovidedi r est f beliefknowledge. <br /> en DateTank®wne <br /> �- <br /> Print Name `7; C-W V1 d Phone (aW x72-,F3;& <br /> Address B f <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑�J ��� <br /> FORM c (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />