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FACILITY INFORNLMON <br /> Business Name: P G * E <br /> Owner/OperatorName: G `'` <br /> Street Address: )-/ o Q Com'L S%� Lart <br /> City: IS 110 C ,I� �J .S <br /> � s,�, Zip Code: � G <br /> Mailing Address: ('� "�' q � <br /> Phone Number: <br /> APPLICANT/CONTPUCTOR <br /> Name: <br /> Street Address: L0 <br /> City: Zip Code: ?-3c 75-`4 Q ST <br /> Phone Number: D t ,'c 77 <br /> Contractor's License Number: Class <br /> Vd 6 ,fes _P,{fIed 6kcl. <br /> Certificate of Worker's Compensation Insurance on file with PHS/EHD? YES NO <br /> UST SYSTEM BLUEPRINT INFORI'VLMON <br /> Y <br /> I wuv -r - c*.Lo r>-sr a c�'i vn �..�. d -3 <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. V Plot plan to show location and number of tanks. <br /> 3 <br />