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PleaseP rovide all information requested. An incomplete application may delay approval. <br /> ❑ FACILITY INFORMATION <br /> Name of Facili x-( <br /> Street Address: <br /> C77-it Z1 Code: <br /> ❑ FORMER NAME OF FACILITY <br /> P •Ar <br /> ❑ BuSINESS OWNER INFORMATION <br /> Business Owner Name: '1! �G• <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: 2S — <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <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 Facili Water Supply: G <br /> Backflow Protection: Y� ( ae <br /> System to be used for Liquid Waste Disposal (Sewage): G <br /> Solid Waste Disposal to beprovided: ugr5na <br /> Grease Interceptor: GX s •�� <br /> ❑ FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Oen: A. r01 Close: 1'2. <br /> Anticipated Number of Employees: <br /> 5 <br /> EHD 16-02-001 Food Plan Check Guide <br /> 6122/04 <br />