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_ <br />n Ss7 <br />Ct� <br />� �� <br />r^'T'if <br />� V i S�fP" '," Z � Y 5 <br />- <br />.' <br />Z✓?a <br />TE OF CALIFORNIA • <br />"1� Y <br />PEso�P�,sc <br />STATE WATER RESOURCES CONTROL BOARD <br />CERTIFICATION OF COMPLIANCElit <br />3°t <br />FOR UNDERGROUND STORAGE TANK INSTALLATION <br />FORM C <br />. <br />Y. <br />r . <br />'• <br />i 4 <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br />I. SITE LOCATION <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 />®; 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 />C7.. Another method was used as allowed by the implementing agency. (Please specify.) <br />:mom'# <br />III.OATH 'I certify that the information provided is true to the best of my belief and knowledge. <br />Tank` <br />Owner/Agent <br />l� % �O_.��'T Date Jan. 10, 198 <br />ate' �%l. <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />