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CITY OF RIPON Fax:2095992685 Sep 17 27 7:03 P. 03 <br /> 08/14/2007 10:38 20940138 ENVSRONMENTAL16LTH PAGE 02/05 <br /> Please provide all information requested. An incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: <br /> Street Address: <br /> City: Zi Code: '3'3 <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> g <br /> ess Owner Namc:Address:n Address: n IL X <br /> Hone Number: n e� n <br /> 13 ftOPERTY OWNER INFORMATION <br /> rKopefty Owner Name: <br /> Homc Address: <br /> M941inz Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFOIRMATION <br /> Name of General Contractor: <br /> Mailinx Address: <br /> Telephone Number <br /> ContactPersoa on Site: <br /> Site Phone Number: <br /> Source of Facility Water SUPPI <br /> Backflow Protection: Y 1/ <br /> s tem to be used for Liquid Waste Vis osal Scwa e : o <br /> Solid Waste Dis osal to beprovided; <br /> Grease Interceptor:' O <br /> 13 FOOD INFORMA'I N <br /> List foods to be served and/or Rrovide menu: 'o be <br /> tib w Ie NsS (et^ C-0 rs c C,011 a . <br /> U OPE xWTIONAI.INFORMATION <br /> Anti i aced Business Hours: Oen: Close: N-x <br /> Anticipated Number of Bm to ees: 2- ¢ <br /> 4 <br /> GRD Woo <br /> ei�noao <br />