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FACILITY INFORMATION <br />Business Name:-... ) <br />Owner/OperatorName• Ouno ` F i <br />Street Address: _ Ino I E- — <br />City: L -D b i 41 (-4 Zip Code:_ Cl � Z40 <br />Mailing Address: 2090 Occ,,j 0-4 N1 vC1,j RACC <br />Phone Number: (2001) <br />APPLICANT/CONTRACTOR <br />W <br />Street Address: LICC LAF Kms' Piv L N i iiJ i c z= i F 1 <br />City: r -A Zip Code: 9z� <br />Phone Number: (4I I S) -4 I n 1 <br />Contractor's License Number: A 3q 13 Class G (A_ � � 4 o <br />Certificate of Worker's Compensation Insurance on file with PHS/EHD? IYES 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. Plans drawn to scale in non -erasable blue print. <br />3. -QL Plot plan to show location and number of tanks. <br />K3 <br />