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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE NO, <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 CA . COUNTY <br /> 11. INSTALLATION (mark all that apply): AUG 0 2 1999 <br /> ENVIRONMENTAL HEALTH <br /> The installer has been certified by the tank and piping manufacturers. PERMIT/SERVICES <br /> 7 The installation has been inspected and certified by a registered professional engineer. <br /> 2EJ��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 /> ❑ Another method was used as allowed by the implementing agency. (Please specify.) <br /> 111. OATH I certify that the informat! ovided Is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 00131�� <br /> Print Name Phone <br /> Address 40er- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# I FACILITY# TANK# <br /> Ei <br /> TANK I.D.# F-177 <br /> C ] I I I I I I <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR003SC7 <br />