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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: <br /> Street Address: _ <br /> City: Zip Code: :o 6, <br /> ❑ FORMER NAME OF FACILITY <br /> 5 �� Q+ nm <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: ej ej <br /> �E <br /> Home Address: 17LI � �� CA <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION . <br /> Property Owner Name: I4H <br /> Home Address: <br /> Mailing Address: Sy LA40 - Cm 4t/2 <br /> Telephone Number: CA <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: o - <br /> Mailing Address: <br /> Telephone Number: `- • -2223 <br /> Contact Person on Site: -T12L=� &-1 <br /> Site Phone Number: �3 _ 22314 <br /> 11 UTILITIES <br /> Source of Facility Water Supply: E% '7 <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): F <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: ,7 11 _ , ®() <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> �i I �2 12 S <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: I l 1}m Close: <br /> Anticipated Number of Employees: () <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />