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z F <br /> i <br /> FACILITY INFORMATION <br /> Business Name: C 1 !& ` <br />- Owner/Operator Name: : c <br /> Street Address: h_!. t�.i , L. �- .J l �� c ,=� C-, <br /> City: Zip Code: <br /> Mailing Address: <br /> e <br /> Phone Number: j z c cels b c� - { <br /> k t P. c' t� ' � <br /> APPLICANT/CONTRA.CTOR <br /> Name: <br /> Street Address: <br /> City: Zip Code: c-, Z v <br /> Phone Number: `-A - 2_ <br /> Contractor's License Number: H Li 0 5 Class (ak 1b,40 <br /> r-, <br /> Certificate of Worker's Compensation Insurance on file avith PHS/EHD? S NO <br /> UST SYSTEM PRINTSET INFORMATION <br /> 1. Four complete sets of plans (To include specification sheets and/or <br /> equipment brochures if not on file). <br /> 2. Plans drawn to scale in non-erasable print. <br /> L31,0�� Plot plan to show location and number of tanks. <br /> J <br />