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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> `..113 <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> :R FORM C ;. . <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ° r . 1 <br /> STREET <br /> CITY COUNTY 3 bA1 <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 /> `( . Q 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 /> ❑ Another method was used as allowed by the implementing agency. (Please specify.) <br /> i <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 77/2t <br /> Print Name Phone (11,d ) — 1 <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> 1 STATE COUNTY# JURISDICTION# FACILITY# _ TANK A% <br /> TANK I.D.# � �� _� F-FTI�� <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />