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STATE OF CALIFORNIA " SovROEs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> P <br /> CERTIFICATION OF COMPLIANCE w ,� <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 /> d �o act .. <br /> CITY r , ONTYcsct <br /> ti. INSTALLATION(mark all that apply): <br /> The installer has been certified by the tank and piping manufacturers. <br /> mil-The <br /> installation has been inspected and certified by a registered professional engineer. <br /> XThe installation has been inspected and approved by the implementing agency. <br /> r II work listed on the manufacturer's installation checklist has been completed. <br /> 9` <br /> ;/IThe 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 t the best of m and knowledge. <br /> Tank Owner/Agent uc. Date J**," <br /> Print Name e-to <br /> Phone <br /> X Address Wes c7d #4 <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# }FACILITY# // TANK# <br /> TANK I.D.# FKf <br /> W 1�+ <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FOR0035C7 <br /> r <br />