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Please provide all information requested. An incomplete application may delay approval. <br /> X$FACILITY INFORMATION <br /> Name of Facility: RALEY'S FUEL STATION #356 <br /> Street Address: 4255 E. MORADA LANE <br /> City: STOCKTON, CA Zip Code: 95212 <br /> ❑ FORMER NAME OF FACILITY <br /> N/A <br /> ® BUSINESS OWNER INFORMATION <br /> Business Owner Name: MIKE GATES c/o RALEY'S <br /> Home Address: <br /> Mailing Address: 500 WEST CAPITOL AVENUE, WEST SACRAMENTO, CA 95605 <br /> Telephone Number: (916) 373-3333 <br /> It PROPERTY OWNER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION T.B.D. <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> Q UTILITIES <br /> Source of Facility Water Supply:CITY OF STOCKTON, MUNICIPAL UTILITIES DEPARTMENT <br /> Backflow Protection: YES <br /> System to be used for Liquid Waste Disposal(Sewage): PUBLIC SEWER CONNECTION <br /> Solid Waste Disposal to beprovided: YES, CITY OF STOCKTON WASTE MANAGEMENT <br /> Grease Interceptor: N/A <br /> ® FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> SEE ATTACHED LIST <br /> ® OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Oen: 5:00 AM Close: 1:00 AM <br /> Anticipated Number of Employees: 10 — 14 <br /> 5 <br /> EHD 16-02-001 Food Plan Check Guide <br /> 6/22/04 <br />