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STATE OFCALIFORMA �E �y•.cs c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE ° <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C " <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET ' I d q 1S <br /> CITY COUNTY <br /> II. INSTALLATION (mark all that apply)-. <br /> The installer has been certified by the tank and piping manufacturers. <br /> iJ The installation has been inspected and certified by a registered professional engineer. <br /> 1 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 /> I_ 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 /> 1 <br /> Tank 0wner!Agent <br /> Date /a <br /> Print Name ���� Phone ( ) <br /> Address <br /> OCAL AGENCY USE ONLY I <br /> STATE (COUNTY# J(UURRIISOIC1TION# FACILITY_# �TAN]�K# <br /> TANK 1.D.# L� .._' _.L__ 1 _i L-1L —1--�—_= ! L <br /> I <br /> F0 M C (7,91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A 3 B UNLESS THEY HAVE BEEN FILED PREVIOUSLY F <br /> OFCG;SC) <br />