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Please provide all inforr 'on requested; an incomplete aF ration may delay approval <br /> [] FACILITY INFORMA-" <br /> Name of Facility: >' <br /> Street Address: <br /> City: Zip Code: 0 2 <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: L_Lkv'l <br /> Home Address: �f,)CD Adal C � <br /> Mailing Address: e+ < <` <br /> Telephone Number: Ccj 52 <br /> ❑ PROPERTY OWNE <br /> Property Owner Name: StOUrAlia WL,4161114 ( L_ <br /> Home Address: `�, tjS , �� o <br /> Mailing Address: W50 (,r I G f q cc (�. <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION 41116 1JEW" <br /> Name of General Contractor: <br /> Mailing Address: -i <br /> Telephone Number: <br /> Contact Person on Site: C d f� <br /> Site Phone Number: 9 <br /> ❑ UTILITIES <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: <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: ryl <br /> Anticipated Number of Employees: <br /> d of A K I rrucrV r_i 11nc <br />