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Please provide all information requested. An incomplete application may delay approval. <br /> A. Name of Proposed Facility: L�u t z_t--30 � Cr 3 fl S <br /> Street Address: 127:F SF' e cic-- I �P-S An �PA C- 5� <br /> city: PA>PJ T e-CA <br /> Zip Code: 9 3 3 <br /> B. Former Name (if any) of Facility: <br /> C. Business Owner's Name : t�rri2tT rJH�ti £Srl� <br /> Home Address: �. ( � �/� ty A t MO -pSS7(- . CA - Y515 <br /> Mailing Address: / <br /> Telephone Number: ( 2,o <br /> D. Property Owner's Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> E. Contractor Information: <br /> Name of General Contractor: > <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> F. Utilities: U T`I <br /> Source of Facility Water Supply: <br /> Backflow Protection: <br /> System to be Used for liquid Waste Disposal (Sewage): <br /> Solid Waste Disposal to be provided by <br /> Grease Interceptor: <br /> 5 <br /> EHD 16-01-001 <br /> REVISED 02-21-02 <br />