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STATE OF CALIFORNIA PES�Vv Esc <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 /> �l J <br /> STREET <br /> CITY �c�" 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 /> The installation has been inspected and approved by the implementing agency. <br /> dAll 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 infor tion provided is true to the best of my belief and knowledge. <br /> Tank Own r/Agent Date <br /> Print Name � "4j I <br /> �., Phone (yos ) c,*-- f� <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE <br /> COUNTY# JURISDICTION# FACILITY# TANK# � SIC <br /> TANK I.D.# <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />