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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY,IN)`QRMATION <br /> Name of Facility: <br /> Street Address: X46G <br /> City: iw\o•. Zip Code: S3 <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATLd <br /> Business Owner Name: e <br /> Home Address: t , CA 61 3 <br /> Mailing Address: CA W1 110 <br /> Telephone Number: pb� 36?11 <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: t✓k� (��055 <br /> Home Address: <br /> Mailing Address: Y.() , %bK 531 1� 1.5„� CA 45 2 <br /> Telephone Number: 3..oct- 41A- tl% <br /> ❑ CONTRACTOR.INFORMATION <br /> Name of General Contractor: �« <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: L.c� russ <br /> Site Phone Number: `loq- 43 G <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: C`t of E cel <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): C:% Esul.� <br /> Solid Waste Disposal to be provided: ;Its <br /> Grease Interceptor: N, <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: 9 bv�,, <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: \ a ti Close: 6� <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />