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Please provide all informa,.,jn requested; an incomplete appi..ation may delay approval <br /> ❑ FACILITY INFORMATION sxMR �z +' <br /> iO QV E2\Pr MO <br /> Name of Facilit : � <br /> Y �f�L�l CI�.�A V Ll <br /> Street Address: &A&? EMDA1T ST <br /> City: STOC.�TO►J C N Zip Code: 95'.OS <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: ��1RDAl�P� L iUILL' j <br /> Home Address: 16/ED E*0 W l.p UJ 1,tJ LA-TOpO C-A 953-30 <br /> Mailing Address: c_ANVh_E <br /> Telephone Number: 73 q K <br /> ❑ PROPERTY OWNER INFORMATION` '° NEW; <br /> Property Owner Name: <br /> Home Address: 1 cx_-,�O tJ <br /> Mailing Address: 5A M C <br /> Telephone Number: qGa <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 Supply: �TbC, — oO_2) 0. T � <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): <br /> Solid Waste Disposal to be provided: LO kQ M. 1P\N1 a <br /> Grease Interceptor: �-- <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> t c e c9__Ca C P (-,I c__e I F V-C)Ts . n K�Q [C-C eF-AM <br /> e_r Do c-r- <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: /j (i! tiLL Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 6/3/13 <br />