Laserfiche WebLink
STATE OF CALIFORNA <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />r= <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <br />N. <br />STREET -2 -5- - <br />CITY COUNTY o- 41 tx /P. <br />II. INSTALLATION (mark all that apply): <br />T Installer has been certified by the tank and piping manufacturers. <br />The installation 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 />F Another method was used as allowed by the implementing agency. (Please specify.) <br />III.OATH I certify thataInforma on pr ided true o t e best of my belief and knovuledge. <br />Tank Owner/Ag t/ 6 V` /j Date <br />Print Name "- ,, Phone ( ) <br />Address <br />6 <br />LOCAL AGENCY USE ONLY <br />STATE ( <br />COUNTY # JURISDICTION # FACILITY # �TANKK ## <br />TANK I.D. # 1 1 1 <br />FtlRM 0 I7re1) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A A 8 UNLESS THEY HAVUEEN FILED PREVIOUSLY F i <br />