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Please provide all information requested; an incomplete application may delay approval <br />FACILITY INFORMATIO <br />Name of Facility: <br />Street Address: ZSo �• (,t <br />City: j . Zip Code: 9572/0 <br />❑ FORMER NAME OF FACILITY <br />O_ BUSINESS OWNER INFORMATI;'. <br />Business Owner Name: rewfi5 +w�GK lila✓ <br />Home Address: �IS-5- Si„' J aw/1 ASO <br />Mailing Address:_ <br />Telephone Number: v e, ry . gd b <br />❑ PROPERDiSiff&INFORMATION <br />Property Owner Name: Soret j of 1--,, <br />Home Address: / ;Lb $. Jllt/If Ay,. ;fes 4 r' Cay.• 2412 - <br />Mailing Address: <br />Telephone Number: xl3IN • 13 L4100 <br />❑ CONTRACTOR INFORMATIO <br />Name of General Contractor: <br />Mailing Address: <br />Telephone Number: <br />Contact Person on Site: <br />Site Phone Number: <br />S__. _ <br />Source of Facility Water Supply: t / P4/ <br />Backflow Protection: Y65 <br />System to be used for Liquid Waste Disposal (Sewage): G 1 — <br />Solid Waste Disposal to be provided: <br />o✓ tl C'e w er <br />Grease Interceptor: BV g <br />List food(s) to be served and/or provid menu: <br />❑ OPERATIONAL INFORMATION <br />Anticipated Business Hours: Open: 7-'Od &AG) Close: 7'CJJ <br />Anticipated Number of Employees: Z <br />EHD 16-01 4 PLAN CHECK GUIDE <br />8/01116 <br />