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V <br /> Please provide all information requested; an incomplete application may delay approval <br /> ORMA <br /> Name of Facility: o%fit_ <br /> Street Address: S36 <br /> City: Zip Code: <br /> ā‘ FORMER NAME OF FACILITY <br /> © BUSIM <br /> Business Owner Name: <br /> Home Address: p 'r <br /> Mailing Address: e, <br /> Telephone Number: 2-eq - 7 p - e)5 '7 <br /> Il ROPERTY NER INFORMATI <br /> Property Owner Name: g <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number. <br /> Source of Facility Water Supply: <br /> Backflow Protection:<a POC <br /> System to be used for Liquid Waste Di po I (Sewage): <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: VjQ& t <br /> ā‘ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> nā€” 7o S 11 u <br /> TI <br /> Anticipated Business Hours: Open: a ) N LS. Close: <br /> Anticipated Number of Employees: <br /> EH016-01 4 PLAN CHECK GUIDE <br /> 8/01/16 <br />