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STATE OF CALIFORNIA .. . <br /> STATE WATER RESOURCES COWROL BOARD <br /> CERTIFICATION OF COMPLIANCE w, ; <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I.SITE LOCATION A&V <br /> STREET <br /> CITY <br /> � COUNTY <br /> 11. INSTALLATION(mark all that apply): <br /> The installer has been certfied by the tank and pissing manufacturers. <br /> [] The installation has been inspected and certrfied 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 checkllst 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 slP"Ry.) <br /> Ill• OATH I certify that the afar ation provl i us to the best of my belief and knowledge. <br /> Tank Owner a Cate <br /> Print Narne _ <br /> Phone ( j <br /> LOCAL AGENCY USE ONLY <br /> COUNTY r! JLFJJSDICTION# FAPILWY# TANK• yl I <br /> STATE <br /> TANK I.D.# �- <br /> FORM r-[W) TAS FORM MUST BE ACCOMPANIED BY PEREI[T APPLICATION FORMS Ari a UNLESS TkEY HAVE BEEN FILED PREVIOUSLY F c� <br />