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N\a <br /> Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMA <br /> Name of Facility: h\ lJA, L-,_ nc�L <br /> Street Address: Soot 'E. CAS-r-v,F_L,,-j 'Dwr. <br /> City: 5•roc_t47rot t C , Zip Code: 9 5 7 <br /> ❑ FORM <br /> ❑ BUSINESS OW <br /> Business Owner Name: l O.D-= <br /> Home Address: pew <br /> Mailing Address: dam=. CeL Z 0 <br /> Telephone Number: ze,j X31 - -7 f,SS <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: A� <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 Facility Water Supply: <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List food(s)to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 12-27-2011 <br />