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• STATE OF CALIFORNIA • PEypy �.;a pp <br />STATE WATER RESOURCES CONTROL BOARD �c <br />CERTIFICATION OF COMPLIANCE ol <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION c�cor� ��``'�`'''Z `0)� <br />STREET <br />CITY COUNTY <br />II. INSTALLATION (mark all that apply): <br />[� The installer has been certified by the tank and piping manufacturers. <br />O> K The installation has been inspected and certified by a registered professional engineer. <br />[VThe installation has been inspected and approved by the implementing agency. <br />D All work listed on the manufacturer's installation checklist has been completed. <br />[q,-- 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 />111. OATH I certify that the information provided is true to the best of my belief and knowledge. <br />Tank Owner/Agent <br />Date <br />Print Name $, ,rem CU Phone <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY # JURISDICTION # FACILITY # TANK # <br />TANK I.D. # 111M 1111111 <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 3 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />