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STATE OF CALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY COUNTY <br /> 11. INSTALLATION (mark all that apply): <br /> x The installer has been certified by the tank and piping manufacturers. <br /> 0 The installation has been inspected and certified by a registered professional engineer. <br /> ;K The installation has been inspected and approved by the implementing agency. <br /> X All work listed on the manufacturer's installation checklist has been completed. <br /> X The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> E:1 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent .-Date, <br /> Print Name Phone <br /> Address A& <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# FT-1 M <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOM 6 D BY PERMIT APPLICATION FORMS A&8 UNLESS THEj6E BEEN FILED PREVIOUSLY <br />