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t 9f <br /> a: <br /> Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: ClIZ112,00AI EXre/t /n/ <br /> Street Address: 33/6 .6, r1�9/N ST <br /> City: ,L'/PION Zip Code: 95366 <br /> [0 FORMER NAME OF FACILITY <br /> /noBiG-6 <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: OZ;68/ kr41/-1-4r <br /> Home Address: <br /> Mailing Address: .336 Z. IWIYI 5/- <br /> Telephone <br /> .Telephone Number: ,209- y07- 9713 <br /> ❑ PROPERTY OWNER INFORMATION _ <br /> Property Owner Name: 3.9m.E <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: T 80 <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: p /�, U J <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 foods to be served and/or provide menu: /r7z&a <br /> ❑_OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: 6 /±i// Close: 9 loom <br /> Anticipated Number of Employees: 11 -13 <br /> EHO 1601 4 PLAN CHECK GUIDE <br /> 715117 <br />