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STATE OF CALIFORNIA E SOV Rimes <br /> STATE WATER RESOURCES CONTROL BOARDIS <br /> CERTIFICATION OF COMPLIANCE 301 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION s JCA <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> e-7 <br /> CITY COUNTY <br /> V <br /> 111. INSTALLATION (mark all that apply): <br /> The 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 /> AIB 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 /> E] Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the=infotion ovided is true to the best of my belief and knowledge. <br /> e <br /> Tank Owne Agen <br /> Date ts 19 e, <br /> Print Name Phone '3 <br /> Address I C, <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# 0013 <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />