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STATE OF CALIFORNIA f5O Roes <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION COMPLIANCE 34Q o <br /> � I <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> • 4L".s NSP <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET N <br /> CITY_ COUNTY tea L, <br /> II. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> D The installation has been inspected and certified by a registered professional engineer. <br /> X 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 /> D 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 �6A/ <br /> -� <br /> Print Narne Phone (914 ) �� <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK 1.D. <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPj§BY PERMIT APPLICATION FORMS A&B UNLESS THEY BEEN FILED PREVIOUSLY <br />