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Please provide all information requested; an incomplete application may delay approval <br /> FACILITY INFORMATION <br /> Name of Facility: _L CC <br /> Street Address: :3 ( / '-1 i:',v <br /> City: -k-c;L%4N-Q , Zip Code: q S Z-G <br /> ❑ FORMER NAME OF FACILITY <br /> z <br /> Lk 1 e -r N -N Lcu <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: L_,k�A' ,S< C,-z-C,r <br /> Home Address: C(•7 p ) GsA v <br /> Mailing Address: <br /> Telephone Number: ;nc( <br /> ❑ PROPERTY OWNER INFORMA <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ COACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address: <br /> Telephone Number: <br /> Contact Person on Site: _ <br /> Site Phone Number: <br /> 1.1 IES M. - <br /> Source of Facility Water Supply: ` \"j ck�\e <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 /> ❑ OPERATION7RWRMARMW <br /> Anticipated Business Hours: Open: W Close: <br /> Anticipated Number of Employees: ` ' <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />