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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE ° <br />FOR UNDERGROUND STORAGE TANK INSTALLATION o' <br />C �a4faa Her . <br />ORM C <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />STREET <br />CITY COUNTY / ON - <br />II. INSTALLATION (mark all that apply): <br />rF <br />rTT Installer has been certified by the tank and piping manufacturers. <br />i <br />he nstallation has been inspected and certified by a registered professional engineer. <br />he 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 />Another method was used as allowed by the implementing agency. (Please specify.) <br />111111. OATH I certify tha t infora °an pr ide true to t e best of my belief and knowledge. <br />Tank Owner/Ag t / Date �.. <br />Print Name ! Phone ( ) <br />Address <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 APPLICATIONFORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />