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Please provide all information requested; an incomplete application may delay approval <br /> Fri FACILITY INFORMATION <br /> Name of Facility: YUj LL-C, t/v,5rLc- 41Wr2,1,41C dmz 4 <br /> Street Address: _3/ s . FAI g)Lljot�j t-3 <br /> City: f VD Zip Code: <br /> ❑ FORMER:NAME OF'FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: '/U.50,0U <br /> Home Address: j /I/F TD�i,i G,GI AY " D) 1?5 46 <br /> Mailing Address: s . l ,y/N� 5ii'-T <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: IV -7- PQW ' ''- <br /> Home Address: 5, �4/ 0 /AUL-. Ste. 3 L-ODI fA <br /> Mailing Address: SAM <br /> Telephone Number: <br /> ❑ CONTRACTOR.INFORMATION <br /> Name of General Contractor: AkAe <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ ,UTILITIES ; <br /> Source of Facility Water Supply: (try pF /-0.0 j <br /> Backflow Protection: ej F L 1 <br /> System to be used for Liquid Waste Disposal (Sewage): L <br /> Solid Waste Disposal to be provided: C/J` <br /> Grease Interceptor: A 1 ,4 <br /> ❑ FOOD INFORMATION ';: .� . `: ';} u ` .<<. 4 <br /> List food(s) to be served and/or provide menu: <br /> /0® COWAN,) <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: a Open: '30AM Close: 2-;30 " <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 8/01116 <br />