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STATE OF CALIFORNIA <br /> 0 0 <br /> sa was <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY— /127 COUNTY <br /> Il. INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> [?J�The installation has been inspected and certified by a registered professional engineer. <br /> 17�The installation has been inspected and approved by the implementing agency. <br /> All work listed on the manufacturer's installation checklist has been completed. <br /> E?I�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 /> Ill. OATH I certify that the inform roLvid !is etrue to the best of my belief and knowledge. <br /> _ ,s t <br /> Tank Owne /Agent, Date 0 <br /> Print Name <br /> Phone C) <br /> Address 0 e <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# �510 1-7 <br /> L <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />