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Please provide all information requested; an incomplete application may delay approval <br /> Name of Facility: (.p�, <br /> Street Address: , <br /> City: trC 16 C Zip Code: 3 3 <br /> Business Owner Name: 91 <br /> Home Address: W� hY1-k P-110 HOCC <br /> Mailing Address: S �� t" y t I ctltCAAS 3� <br /> Telephone Number: p { <br /> Property Owner Name: DA\,( (t) KOEG <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> Name of General Contractor: O rr o (' PM)05 r <br /> Mailing Address: <br /> Telephone Number: _ u_ -'"C5 <br /> Contact Person on Site: b r r? p VIS OS <br /> Site Phone Number. R Ct 12— l790 -7o J g IS <br /> Source of Facility Water Supply: },b.t111:7- C l { (AJ —FFfZ <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): C(-T-( s-rtA_) �i <br /> Solid Waste Disposal to be provided. WA 3Tf' 1 t ��' �-— <br /> Grease Interceptor: V (d2(7 <br /> List food(s) to be served and/or provide menu: I G V�: G(LF� <br /> Anticipated Business Hours: Open: j0ioo Close: _ 4,' p0 <br /> Anticipated Number of Employees: 96A C 14 l P( <br /> EHE 16-01 4 PLAN CHECK GUIDE <br /> 8101116 <br />