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r <br /> STATE OFCAUFORNA <br /> STATE WATER RESOURCES CANTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM 1`011i EACH TANK SYSTEM <br /> 1.SITE LOCATION � � <br /> STREET �.P)106 <br /> CITY ala t� <br /> COUNTY <br /> Il. INSTALLATION (r�ark ail tinat apply): <br /> The installer has been Certified by the tank and piping manufacturers. <br /> [] The Installation has been inspected and certified by a regfsterod professional engineer. <br /> The installation has been Inspected and approved by the implementing agency, <br /> l All work listed on the manufacturers installation checklist has been Completed. <br /> . The Installation contractor has been certified or licensed by the Contractors State License Board, <br /> L2 Another method was used as allowed by the Implementing agency. (Please specify.) <br /> 111.OATH I certify that the nfo ation prov ed to Ir a to the best of my belief and knowledge. <br /> Tank own! ge - Date <br /> Print Name p Phone <br /> t a Ss1- <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JUAISISICTION a FACILITY a � <br /> TANK I.D.# TANK* <br /> r+�RM c Pro'! THIS FORM MUST BE ACCOMPANIED BY PERIAIT APPLICATION FORNIB A 8 UNLESS THEY HAVE BEEN FILED FFIEVIOUS[Y f�scy <br />