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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `= <br /> CERTIFICATION OF COMPLIANCE W mom° m <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <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 /> IP/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 /> Ea�'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 and licensed by the Contractors State License Board. <br /> C 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 7-,,,//l <br /> Print Name ® f"a Phone <br /> Address / Dd®A�0- <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# ( FACILITY#Y STAN(K�#r�{� <br /> TANK I.D.# � � l I( <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORD035C8 <br />