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STATE OF CALIFORNIA 'ov .c. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> CERTIFICATION OF COMPLIANCE <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> 1. SITE LOCATION <br /> STREET <br /> CITY COUNTY <br /> 111. 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 and 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 Date 4 —fZ <br /> Print Name Phone ( ) <br /> Address <br /> LOCAL AGENCY USE ONLY <br /> STATE COUNTY# JURISDICTION# FACILITY TANK#T-T� <br /> TANK I.D.# F-F= I I I I <br /> FORM C (6/95) THIS FORM MUST BE ACCOMGFD BY PERMIT APPLICATION FORMS A&B UNLESS THE BEEN FILED PREVIOUSLY FOR0035U <br />