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0 0 <br /> Please provide all information requested; an incomplete application may delay approval <br /> FACILITY INFORMATION <br /> Name of Facility: Ce , I-W � o,s S4,tc <br /> Street Address: 6 20 r- y r e 1' <br /> City: C- - c�A Zip Code: 5Z 0 G <br /> ❑ FORMER NAME OF FACILITY <br /> S Am <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: 6'2-v y Gid rbc r L e <br /> Home Address: 0-0y-W, y Y <br /> Mailing Address: <br /> Telephone Number: O O <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: 62- vy . C4%*Jex <br /> Home Address: <br /> Mailing Address: cam. <br /> Telephone Number: S-q, -7 41 , <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: &Va-0,5" C-- <br /> Backflow <br /> ;Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): C= <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: (� <br /> ❑ FOOD INFORMATION <br /> r; <br /> List food(s) to be served and/or provide menu: <br /> r2 c•c <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: yN 1,%-x Open: Close: <br /> Anticipated Number of Employees: Li <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 12-27-2011 <br />