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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFOR A IONS <br /> Name of Facility: <br /> Street Address: lV <br /> City: Zip Code: <br /> 0 FORMER NAME OF FACILITY <br /> _ h <br /> ❑_BUSINESS OWNER INFORMATION _ <br /> Business Owner Name: D <br /> Home Address: IU44 Wildf S 3 <br /> Mailing Address: pa bQXQ' LOC f <br /> Telephone Number: Cloa- 08 <br /> a„PROPERTY OWNER INFORMATION; <br /> Property Owner Name: . Q <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 /> ❑ UTILITtE <br /> Source of Facility Waters up �YV <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): O V 1 <br /> Solid Waste Disposal to be provided: 0!1 ( CL WOLSte 06poS <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> e <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: '7 O Close: <br /> Anticipated Number of Employees: - <br /> EHD 16-01 4 <br /> 715117 PLAN CHECK GUIDE <br />