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FACILITY INFORMATION <br />Business Name:—...,,, Use, <br />Owner/OperatorN <br />0 <br />Street Address:.,,., 1! l & 0 /1* S7' <br />City: Zip Code:�376 <br />Mailing Address: - <br />Phone Number: LyzS_T_ <br />Name: <br />Street Address: <br />City: Zip Code: <br />Phone Number: <br />Contractor's License Number: Class <br />Certificate of Worker's Compensation Insurance on Me with PHS/EEO)? YES <br />1. Fotfr complete sets of plans (specification sheets and/or equipment <br />brochures if not on file). <br />2. Plans drawn to scale in non -erasable blue print. <br />3. L//Plot plan to show location and number of tanks. <br />K <br />=4 <br />