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Please provide all information requested; an incomplete application may delay approval <br /> Y INFORMATION <br /> Name of Facility. tlabt b, aft IrI-I or,01 ftrlC6- 1 <br /> Street Address: ►J. ryNain S+ree_+ <br /> City: A Zip Code: Cis zgw <br /> Business Owner Name: Oil ny\C4 Oph Marl <br /> Home Address: yco-C-16 <br /> Mailing Address: , eC of S <br /> Telephone Number: Z <br /> Property Owner Name: rd a h yt <br /> Home Address: <br /> Mailing Address: D � <br /> Telephone Number: rCAM Vio rs Cl 99LLA <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> Source of Facility Water Supply: <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): L^ <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: <br /> List food(s)to be served and/or provide menu: <br /> Anticipated Business Hours: Open: Close: Gt <br /> Anticipated Number of Employees: W <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 8/1/14 <br />