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STATE OF CALIFORNIA PES,vy,ES c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY COUNTYsc �� � <br /> II. INSTALLATION (mark all that apply): <br /> dThe installer has been certified by the tank and piping manufacturers. <br /> �j The installation has been inspected and certified by a registered professional engineer. <br /> dThe installation has been inspected and approved by the implementing agency. <br /> lt<AII 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 /> Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the infor pro ' true to the best of my belief and knowledge. <br /> Agent <br /> Tank Owne !-7, - Date / <br /> O`C' <br /> Print Name - Phone <br /> Addresses <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# S �� <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />