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STATE OF CALIFORNIA PfSOVH ESQ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE ad °, <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 �r—�!. COUNTY <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 /> d The installation has been inspected and approved by the implementing agency. <br /> 3?"I"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 /> D Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the info atiorll pro ' is true to the best of my belief and knowledge. <br /> Tank Owne Agent DateCv <br /> Print Name '� Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUmNTY# JURISDICTION# FACILITY# TANK# J ice ' 4� <br /> TANK I.D.# t�I / L510 L51-16 Y <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />