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7—T 7777 <br /> 40 <br /> STATE OF CALIFORNIA sovRcEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION F COMPLIANCE 3` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> ° <br /> • °�IIFpR N" <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY COUNTY AI- a A1d1AZ <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 /> 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/AgentZDate <br /> T <br /> Print Name / G Phone ( <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOM ED BY PERMIT APPLICATION FORMS A&B UNLESS THE VE BEEN FILED PREVIOUSLY <br />