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se provide all information •equested. An incomplete ap "cation may delay approval. <br /> FFACILITY INFORMATION <br /> Name of Facility: / <br /> Street Address: 003 S fl d yd o 46 <br /> City: 5 DCS d,v Zip Code: Ai5c <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: /0 eo w.5 le,CK <br /> Mailing Address: <br /> Telephone Number: (�T2 o <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: /7/1 <br /> Home Address: ©3 /l/ C-c,w S o c/e t <br /> Mailing Address: 10 e <br /> Telephone Number: -.0 yo f s --Ie vc <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: `'L <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: w.2 c-r /S I,✓-? cy <br /> Backflow Protection: o w k? <br /> System to be used for Liquid Waste Disposal (Sewage): <br /> Solid Waste Disposal to beprovided: <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> le-e, <br /> r7'cr�DY�i ' <br /> �/ rf <br /> r�� yfv,CiS <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Oen: //.-/w Close: 6•Tv cg� 'f <br /> Anticipated Number of Employees: 3 <br /> 4 <br /> EHD 16-02-001 Food Plan Check Guide <br /> 5/22/03 <br />