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V <br />FACILITY INFORMATION <br />Business Name: �O EiN TA L1 Log- Frc 2-iZ L l T1rCR <br />Owner/Operator Name: JAVLOP-- 1d16 1K,, i <br />Street Address:_ p� ` i 81 °l �_ l� NAu i <br />City: �7TlxK7/�1 Zip Code: ?SZO6 <br />Mailing <br />Phone Number: gig 9/S/ <br />M <br />APPLICANT <br />p/CONTRACTOR J <br />Name: ym to <br />Street Address:_ Y�il W KfiCC L f gD <br />City: gpwo Zip Code: 9S3St <br />Phone Number: <br />Contractor's License Number: Class G6/ /, Wo <br />Certificate of Worker's Compensation Insurance on file with PHS/EHD? "YDS NO <br />UST SYSTEM BLUEPRINT INFORMATION <br />1. Four complete sets of plans (specification sheets and/or equipment <br />brochures if not on file). <br />2. V//"Plans drawn to scale in non -erasable blue print. <br />3. Plot plan to show location and number of tanks. Sec Akorleesl 15wt /' /ovfL <br />3 <br />