Laserfiche WebLink
, . r • <br /> Please provide all informftn requested. An incomplete applic ... n may delay approval. <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: <br /> Street Address: <br /> City: Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: <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 beprovided: <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Oen: Close: <br /> Antici ated Number of Em to ees: <br /> 4 <br /> EHD 16-01 <br /> 8/42006 <br />