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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: Deo d d ds <br /> Street Address: d d d d Pacific Aved <br /> City: Stocd too Zip Code: d d d d d <br /> ❑ FORMER NAME OF FACILITY <br /> Sao e <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: ValleO Did er Mad aU ed ed E ID C <br /> Home Address: IUUJ Moo rd Aved 0 0 0 0 Frel o0 t0 CA 0 0 0 0 0 <br /> Mailing Address: <br /> Telephone Number: dd d 0d d d d dd d d d <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: Sad e <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: Williad Ross d Qualit0 Choice Cod structiod <br /> Mailing Address: d d d d SD Nellis Blvdd Suite 0 0 0 0 Las Vel as[ NV 0 0 0 0 0 <br /> Telephone Number: dd d d d d d d H d d d <br /> Contact Person on Site: Bol Rod <br /> Site Phone Number: dd d d ddd d d dd d d d <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: Stocd tod East Water District <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: See Med u <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: d d hours Close: <br /> Anticipated Number of Employees: d d <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />