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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: )' <br /> Street Address: <br /> City: Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> 9 BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: ���' j <br /> Q PROPERTY OWNER INFORMATION <br /> Property Owner Name: Fq'u ki 0 O Loie_ <br /> Home Address: COr Y GLix <br /> Mailing Address: epn <br /> Telephone Number: q4,q • 7(s0 S / <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> M-UTILITIES <br /> Source of Facility Water Supply: Pc e, L, <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): <br /> Solid Waste Disposal to be provided: <br /> Grease Interceptor: #:7 <br /> ❑ FOOD INFORMATION <br /> List food(s)to be served and/or provide menu: <br /> 2 A JG f G - v <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: 2 <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 11-14-08 <br />