Laserfiche WebLink
STATE OFCALIFORMIA • �sov�ces <br /> STATE WATER RESOURCES CONTROL BOARD M1e •�, <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION ° <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ��"( `��'`1�� "S�P <br /> STREET `'� ti <br /> CITY —rizA C, COUNTY SAr) 7of c \)[t*j <br /> II. INSTALLATION (mark all that apply): <br /> ' The installer has been certified by the tank and piping manufacturers. <br /> F-1 The installation has been inspected and certified by a registered professional engineer. <br /> 0 The installation has been inspected and approved by the implementing agency. <br /> t!j' All work listed on the manufacturer's installation checklist has been completed. <br /> �he installation Contractor has been certified or licensed by the Contractors State License Board. <br /> 0 Another method was used as allowed by the implementing agency. (Please specify.) <br /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agen� Date Z <br /> Print NamePhone ( } <br /> Address r <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY#1-79q <br /> TANK# 00 <br /> TANK I.D.# F—F] Q 1-71213 1-71 �6 171 V I TZ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY <br />