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STATE OF CALIFORNIA 0 <br />STATE WATER RESOURCES CONT ROL BOARD <br />CERTIFICATION OF COMPLIANCE <br />STREET al _q <br />CITY —4'' 5'5�' COUNTY -�'fD"&IIV <br />11. 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 />T5?r- The installation Contractor has been certified or licensed by the Contractors State License Board. <br />E] Another method was used as allowed by the implementing agency. (Please specify.) <br />Tank Owner/Agent <br />Print Name <br />LOCAL AGENCY USE ONLY <br />STATE COUNTY# <br />TANK I.D. # FT -1 <br />Date <br />..,hone <br />rd, , l'i " 1111 <br />��C � W10 1� 0. 1 Em F&M I I <br />JURISDICTION # FACILITY # TANK # <br />FEE �I 1 15101 <br />FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A & B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br />