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0 0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ,� a <br /> a <br /> CERTIFICATION OF COMPLIANCE W mom. <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION - <br /> �+twoww`P' <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 /> 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 /> E�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 /> Cu'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 /> 21a M Tank Owner/Agent Date j <br /> Print Name 4r Phone <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY# r TANK# <br /> TANK I.D.# F-T-1 1117 F-Lill 11 <br /> I <br /> FORM C (6/95) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C8 <br />