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INSTRUCTIONS FOR CO PL FORM "C`: TANK INSTALLATION C*ICATION <br /> This form is required for piping replacements, but not piping repairs, <br /> GENERAL INSTRUCTIONS <br /> 1 Each tank system must be in compliance with the federal and state technical standards, <br /> contained in law and regulations, for tank and piping installation, <br /> 2, This certification shall be completed by either the LIST owner or representative. <br /> 3. One certification is required for each tank system. This form shall be used to make the <br /> required certification. <br /> 4Please type or print clearly all requested information (for printing, please use a hard point <br /> writing instrument). <br /> S. Submit the completed certification to the appropriate Local Implementing Agency, <br /> I. INSTALLATION: MARK ALL OF THE ITEMS THAT APPLY TO INDICATE THAT THE <br /> INSTALLATION REQUIREMENTS ARE MET. <br /> ll. OATH: THE TANK OWNER OR AGENT SHALL CERTIFY, BY SIGNING THE CERTIFICATION, <br /> THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. THE PERSON'S <br /> NAME SHOULD BE PRINTED UNDER THE SIGNATURE. <br /> INSTRUCTION FOR THE LOCAL AGENCIES <br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the <br /> State Board (91 6) 227-4303. The facility number may be assigned by the local agency; <br /> however, this number must be numerical and cannot contain any alphabetical characters, <br /> If the local agency prefers the State Board to assign the facility number, please leave it blank. <br /> It is the responsibility of the local agency that inspects the facility to verify the accuracy of the <br /> information. The local agency is responsible for the completion of the "local agency use only" <br /> information box. The local agency should retain the original and yellow copies. The pink <br /> copy should be retained by the tank owner. <br />