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z <br />STATE OF CALIFORNIA f 5pu RC E S <br />q STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE w <br />FOR UNDERGROUND STORAGE TANK INSTALLATION s <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM cs <br />f� <br />I. SITE LOCATION <br />LO <br />STREET <br />CITY e- 'l COUNTY .� <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 />F�. ] 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 information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent Date, — / <br />Print Name Phone ( i ) —O 2 <br />Address 6 <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # ❑❑�� <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />