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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: <br /> Street Address: 1 b <br /> City: Zip Code: elS3 <br /> ❑ FORMER NAME OF FACILITY <br /> K& /n1 leo <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: Cetllj& L. <br /> Home Address: A05 W. 2-15+ 1r3 76 <br /> Mailing Address: 20 S UU, I '* S 7 953 <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ONTRACTORINFORMATION <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 Disposal (Sewage): <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION, <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: 6A,.4-Vg Open: - T Close: 5 <br /> Anticipated Number of Employees: <br /> EHO 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />