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STATE OF CALIFORNIA 5puq�� <br /> STATE WATER RESOURCES CONTROL BOARD :�eE • •+S°ow <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION W �� <br /> I � <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> &Iw, <br /> CITY COUNTY <br /> ll. INSTALLATION (mark all that apply): <br /> 0 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 /> F-� 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 /> Qfi 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 the information provided is true to the best of my belief and knowledge. <br /> 0 <br /> Tank Owner/Agen � Date 11--95 <br /> Print Name a ' (,Q 16 )9 <br /> �. Phone <br /> Address 8 Snap- r eA)l (A) <br /> e <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# M ��� ITE <br /> Fonm G (7181) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> 0 0 <br />