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STATE OF CALIFORNIA sovMOE <br /> E S <br /> ' STATE WATER RESOURCES CONTROL BOARD <br /> A <br /> CERTIFICATION OF COMPLIANCE Wo <br /> lit <br /> FOR UNDERGROUND STORAGE TANK INSTALLATIONFORM C <br /> • C"t/FUM N.P <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION co C t l / C7 / w <br /> STREET Q <br /> CITY COUNTY Lt <br /> ll. INSTALLATION (mark all that apply): <br /> The 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 /> 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 /> Ill. OATH I certify that the information provided is true to the best of my belief and knowledge. <br /> Tank Owner/Agent C _� _ (,� Date <br /> Print Name `S ° � Phone ( (p) ,0 _ <br /> Address _ k^ O <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 FORMES A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR1111C7 <br />