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STATE OF CALIFORNIA �Ea ,s o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE W <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> C4Cic°p NSP. <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION / <br /> STREET '� <br /> CITY DR06&TO17COUNTY A 7— <br /> II. INSTALLATION (mark all that apply): <br /> [ '"The installer has been certified by the tank and piping manufacturers. <br /> e installation has been inspected and certified by a registered professional engineer. <br /> �The installation has been inspected and approved by the implementing agency. <br /> 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 /> ❑ 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/Agent Date / <br /> Print Name Phone ) 2 74 <br /> Address / Z <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# <br /> TANK I.Q.# ❑ ❑❑�—�� 1 EI r—I—] <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />