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STATE OF CALIFORNIA �SouacEs <br /> P puMawq cp <br /> :.STATE WATER RESOURCES.CONTROL BOARD �P <br /> CERTIFICATION PLI C <br /> STORAGEFOR UNDERGROUND INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FOR F R EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> TET <br /> COUNTYCITY <br /> C-1 <br /> IL INSTALLATION (mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> 0 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 /> Another method was used as allowed by the implementing agency.'(Please specify.) <br /> III.OATH I certify that the information pr `vi is true est of my belief and knowledge. <br /> Tank Owner/Agent Date 9L i <br /> Print Name 6x('J` t t 14�1( Phone <br /> Address t 1 J <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D. L_ I I I <br /> FORM C (list) THIS FORM MUST BE ACCOMPANIED Y PERMIT APPLICATION FOR A UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />