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• STATE OF CALIFORNIA • pE ao� R,s�� <br /> STATE WATER RESOURCES CONTROL BOARD W "� <br /> CERTIFICATION OF COMPLIANCE w ' <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION <br /> STREET <br /> CITY ' 'd COUNTY <br /> 11. 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 /> 111. OATH I certify that th 1 formation pr lided is true to the best of my belief and knowledge. / <br /> Tank Owner/Agent Date <br /> Print Name Phone (zt9 )835�7�5G <br /> Address !a,� <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# EE <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />