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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMA ,ON ..- <br /> Name of Facility: / L <br /> Street Address: <br /> City: Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: N - 3 <br /> Mailing Address: <br /> Telephone Number: a <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 Disposay.Sewage : <br /> Solid Waste Disposal to be provided: I�Z42:vK A4 <br /> Grease Interceptor: _v <br /> ❑ FOOD INFORMATION' <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION - <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employee's: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 8/1/14 <br />