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J . <br />FACILITY INFORMATION 0 CT 0 7 1992 <br />' ENVIRONMENTAL HEALTH <br />Business Name: �,l{20Q RE MI 1 T-!6 ERV 1 G E -S <br />Owner/Operator Name: NoW E eff_n l S TIMI✓ <br />Street Address:11 U3 ST96EFT <br />City:_ M,6�t�1"T'�G.�. Zip Code. <br />Mailing Address:_ <br />Phone Number: '(SIS 'Tillie <br />APPLICANT/CONTRACTOR <br />A.� co -WT : 'C�, f W. WM - IZ05C M f H- Las* /4�oclA'1�S C-7cr!> 7lv5 I Co (c 0 <br />Name: W EW rrr Cg>M !$'['I2c1L'rI DN <br />Street Address:_ G '9T N4OaSe 90 <br />City: Uooi Zip Code: I 1 ?A 1 <br />Phone Number: (IM ) a6!( 'I 30152 <br />Contractor's License Number: Class_, i j, G' 1 d IHpti-a- Mi4r ' <br />Certificate of Worker's Compensation Insurance on file with PHS/EEG)? L/YES 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. ✓ Plot plan to show location and number of tanks. <br />3 <br />