Laserfiche WebLink
FACILITY INFORMATION <br />Business Name: _ ON Off. ,,!50a✓k <br />Owner/Operator Name: f- IW(.gk <br />Street Address: _ I K� LEt-1P1--1 . <br />City: L-0 171 Zip Code: '91:-:1z_40 <br />Mailing Address: <br />Phone Number: (�L09 -0-7�j <br />APPLICANT/CONTRACTOR <br />Name: <br />Street Address: <br />City: Zip Code: <br />Phone Number: 1 ) <br />Contractor's License Number. Class <br />Certificate of Worker's Compensation Insurance on file with PHS/EHD? YES NO <br />UST SYSTEM BLUEPRINT INFORMATION <br />1. <br />/Four com lete sets of plans (specification sheets and/or equipment <br />brochures if not on file). <br />2. i/ Plans drawn to scale in non -erasable blue print. <br />3. i/ Plot plan to show location and number of tanks. <br />K <br />