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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: A <br /> . r-01JE(311L <br /> Street Address: S[.r/ ,quFIL 14yj;7 <br /> City: C�" 6,L 41V Zip Code: S v <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION _ <br /> Business Owner Name: hE,,VA <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: fk <br /> Home Address: 51 S1 Af A S2 <br /> Mailing Address: <br /> Telephone Number: 20,�F Cf IFFS xr <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: 121E ' <br /> Mailing Address: <br /> Telephone Number: J —S <br /> Contact Person on Site: S <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: <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 /> l <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: `7,`J 0A- Close: : DU <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />