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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: Sha,, — E— u A ✓` Gqv-­2 <br /> Street Address: 2 c S (� <br /> City: Zip Code: S2 Z <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: <br /> Mailing Address. 3 Zo c— S S CACIA <br /> Telephone Number: o o <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: Le,(( arc <br /> Home Address: <br /> Mailing Address: '� Csam m S rc a� o Cid cl '-1 0 <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: D <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: Min� t,✓ c.�( <br /> Backflow Protection: e S <br /> System to be used for Liquid Waste Disposal (Sewage): Mu,nt��c b-Q <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: S <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 12-27-2011 <br />