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$TATE OF CALIFORNIA <br /> e " <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION °s '➢ <br /> �,nr <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET „„�� �� aa ` <br /> CITY l�P `—W Q 0 COUNTY M" U 1 N <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 /> 0 Another method was used as allowed by the implementing agency. (Please specify.) <br /> III. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> ,r1 I <br /> Tank Owner/Agent `? � Date V <br /> -- -- - — - — <br /> Print Name j /�/Phone ; ) <br /> Address . Cr —T k p mac- 4 <br /> r l� 'q_ - <br /> LOCAL AGENCY USE ONLY �/ <br /> STATE: COUNTY# JURISDICTION# FACILITY# _ TANK# �J <br /> TANK I.D.# Tq = �} t <br /> r <br /> FORM C (7rsi) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOROMC7 <br />