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STATE OF CALIFORNIA i �Nou <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE 3` <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION 4 <br /> .i <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET ( .. <br /> CITY COUNTY <br /> II. INSTALLATION (mark all that apply): <br /> 0 The installer has been certified by the tank and piping manufacturers. <br /> Q The installation has been inspected and certified by a registered professional engineer. <br /> [2 The installation has been inspected and approved by the implementing agency. <br /> E-�j 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 provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent C '{` i <br /> � >� �- Date 1-28-00 <br /> Print Name George Takemori Phone (916 )386-3716 <br /> i <br /> Address P.O. Box 15002 Sacramento, CA 95851 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# EFT] <br /> FORM C (7191) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&8 UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />