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Please provide all information requested. An incomplete application may delay approval. <br /> ❑ FACILITY INFORMATION <br /> NameofFacili .f �Y VYDf�d� <br /> Street Address: 3 D 2 <br /> ip Code: <br /> Citv: <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: Aio1 C <br /> Home Address: 3 <br /> Mailin Address: 3S-rn MDW <br /> Tele hone Number: S I U -7°1 - 3 <br /> ❑PROPERTY OWNER INFORMATION <br /> Pro erty Owner Name: W-u (vv,Y)d-61 <br /> Home Address: 3 <br /> Mailing Address: 3U 90 C UK • C <br /> Telephone Number: - 4 9 L4 <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑UTIIdTIES <br /> Source of Facility Water Su Iv: <br /> Backflow-Protection: <br /> System to be used for Li uid Waste Disposal (Sewage): <br /> Solid Waste Disposal to beprovided: <br /> Grease Interceptor: <br /> ®FOOD INFORMATION <br /> List food(s)to be served and/or provide menu: - rAsf �o U2s or ln'u <br /> z " z <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: D <br /> Anticipated Number of Employees: 20 <br /> 5 <br /> EHD 16-02-001 Food Plan Check Guide <br /> 6/22/04 <br />