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STATE OF CALIFORNIA PEsoV..,a�o <br /> STATE WATER RESOURCES CONTROL BOARD .P a <br /> CERTIFICATION OF COMPLIANCE <br /> STORAGEFOR UNDERGROUND TANK INSTALLATIONFORM C <br /> • CSC/FOP H.P <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION <br /> STREET <br /> CITY _ _ COU N T Y /7 <br /> II. INSTALLATION (mark all that apply): <br /> [eThe installer has been certified by the tank and piping manufacturers. <br /> 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 /> KI�Nll 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/Agento /I e/,rov <br /> Date /�- <br /> Print Name Phone <br /> Address / DW-7- <br /> LOCAL <br /> _ 7" f <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# TANK# _ <br /> TANK I.D.# ❑ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0095C7 <br />