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Please provide all information requested. An incomplete application may delay approval. <br /> 4 FACILITY INFORMATION <br /> Name of Facility: C7 P �(� G <br /> Street Address: p(j C2 -C <br /> Ci :- TS C. -j 0- Zi Code: <br /> ❑ FORMER NAME OF FACILITY A1--*wc <br /> E3 BUSINESS OWNER INFORMATION <br /> Business Owner Name: M a V 1 C' DE(� <br /> Home Address: '7-0 � � C, -g,Z <br /> MailingAddress: cT 0yo !� �rW <br /> Telephone Number: 2a9 . q1t <br /> ❑ PROPERTY OWNER INFORMATION <br /> . Property Owner Name: <br /> Home Address: q(,6/ C H lNAr F <br /> Mailing Address: Z <br /> z-/I;Y1 <br /> Telephone Number: i�63 Cj <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Su 1 / t q ` <br /> C �.y V Vr 1 <br /> Backflow Protection: J2 <br /> System to be used for Liquid Waste Disposal (Sewage : C I T <br /> Solid Waste Disposal to be rovided: w . M <br /> i oC(ct�xv <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Antici ated Business Hours: Oen: - i�1 <br /> Anticipated Number of Employees: Close: <br /> bry _ <br /> EHD 16-01 4 <br /> 8/4/2006 <br />