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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: PA-N A Ex <br /> Street Address: 142-. 665T CoLoM`r RoAC> <br /> City: Plpz>m CAL,(Po )A Zip Code: If 53G6 <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: GFT' Dt:V�(,pi'!') rS LLG <br /> Home Address: I Co$3 , 1A4W&7' <44R6V.0 AVe'. CA 91770 <br /> Mailing Address: &(.g 3 t4441 R6V6 A0E. 4 <br /> Telephone Number: G 2,G_ 372- 210 <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: G 1VV E SEL p L LG <br /> Home Address: (Co$ ALIfUT 6ROVE AV6: RpSf M aAD CA 9 1170 <br /> Mailing Address: (0 8 N'uTr-(ovE AvF- MF-AD CA c1l 770 <br /> Telephone Number: 626 -372-&G26 <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: 1 <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: Ho S70 AV6A71',9 �/S GT - lam" ,S/1 yim/,tJ1b �!r'4T <br /> Backflow Protection: YDS. S��G$.o � 4t. C/r �it/S o -2 . <br /> System to be used for Liquid Waste Disposal (Sewage): 56 6"1./•Jr. <br /> Solid Waste Disposal to be provided: TWO T 5 ���tJFiQ,s G � GGd <br /> Grease Interceptor: Joao eqa„LS <br /> ❑ FOOD INFORMATION _ <br /> List food(s) to be served and/or provide menu: C G <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: la:3o .6, Close: 10=oa Em <br /> Anticipated Number of Employees: 15 —A <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />