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INSTRUCTIONS FOR COMPLETING FORM "C"; TANK INSTALLATION CERTIFICATION <br />GENERAL INSTRUCTIONS <br />1. Each tank system must be in complianc%L.4,0) the federal and state technical <br />standards, contained in law and regulations, to-r4p*k-Awd piping installation. <br />2. This certification shall be completed by elther the UST owner or representative. <br />3. One certification is required for each tan'V. !;yslern.. This form shall be used to <br />make the required certification. <br />4, Please type or print clez-,111 reque�'ind 14—iiation (for printing, please use a <br />hard point writing instrument , ). <br />5. Submit the completed certification to the appropriate Local Implementing Agency. <br />1. INSTALLATION: MARK ALL OF THE ITEMS THAT APPLY TO INDICATE THAT THE <br />INSTALLATION REQUIREMENTS ARE MET. <br />II. OATH: THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE <br />CERTIFICATION, THAT THE INFORMATION PROVIDED IS TRUE AND Now <br />"woo CORRECT. THE Ef,5aaS NAME SUgghQ.FAL"INTED UNDER THE <br />SIGNATURE. <br />XW--*1*)ft 'gajaftj�.-'x 'a :'l M... "A W <br />0 <br />