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igjUUU <br /> 07/29/2002 14:44 FAX __ _.... <br /> Please provide all information requested. An incomplete application may delay approval. <br /> - i,J. T505R <br /> A. Name of Proposed Facility: G1 � £ E k5 of I}DI MVJa RDAD <br /> Street Address: t^itroKE) FREDNoRiN of H <br /> ZipCode: <br /> City: S tL7 <br /> B. Former Name (if any) of Facility: <br /> C. Business owner's Name <br /> Home Address: <br /> 205-25 <br /> Mailing Address: 19 Pl• EL <br /> NA DRl L 95 <br /> Telephone Number: <br /> 209 -153 <br /> D• Property Owner's Name: <br /> Home Address: <br /> Mailing Address' <br /> Telephone Number: <br /> E. Contractor Information: NONE k5 OF Tf-i't5 DhTE <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number <br /> Contact Person on Site: <br /> Site Phone Number. <br /> F. Utilities: <br /> Source of Facility Water Supply: CITY OF �roLKTbh�yMuN1GIPF\i- �T1LLC1- 5 �' <br /> Backflow Protection: (oI BA�KFIocJ V <br /> System to be Used for liquid Waste Diseosal(Sewage): 10" SE-WEA iN �� Kt75so D I <br /> Solid Waste Disposal to be provided by <br /> Grease Interceptor. ��NSFr l MOD•a JZ5[Q�F� - 5000 jf,A - AF <br /> 5 <br /> END 16-01401 <br /> REVISED 02-21-02 <br />