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• STATE OF CALIFORNIA • PESOUA TEgc <br /> STATE WATER RESOURCES CONTROL BOARD A=• °ti. <br /> CERTIFICATION OF COMPLIANCE W ,� <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION as f • �r <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET 67774, <br /> CITY �.��X�Ch�C�9�/li0 COUNTY <br /> II. 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 /> ❑ 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 /> III. OATH I certify that the information p ovi ed is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date �/7/,, <br /> Print Name Phone Z7,fZD <br /> Address O )(fo <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# ❑ IL _1-_I <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />