Laserfiche WebLink
R <br />STATE OF CALI RNIA 19W <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />F <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SfOTAV�,. <br />ool> qc, [ <br />STREET 2E <br />CITY COUNTY 02E02=�Uub <br />U <br />111. INSTALLATION (mark all that apply): <br />WrThe 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 />El Another method was used as allowed by the implementing agency. (Please specify.) <br />OATH I certify that the information provided is true to the best of my belief and knowledge. <br />A . .10 1 <br />Tank Owner/ <br />Drinf Kinmn <br />Address <br />Date ff- IT - <br />q ��- <br />STATE COUNTY# JURISDICTION # FACILITY # TANK # <br />TANK I.D. # FT� F -F -F I I 1-1= I 1 1 17= <br />FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />