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w STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD 10 <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 & /671 17 <br />CITY COUNTY <br />II. INSTALLATION (mark all that apply): <br />[jZ 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 />[v� 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 />111. OATH I certify that the <br />Tank Owner/Agent <br />Print Name ?aA / r, <br />ded is true to the best of my belief and knowledge. <br />Date /o --yo — o <br />Phone ( >,� ) 9 <br />Address (�'1 N az <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # F -T-1 L[ I I I I � [- <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & 8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />