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II: COMPANY DETAILS <br />1 <br />j1. NAME OF AGENCY: ` C`�e "t <br />MAILING ADDRESS: <br />CITYSCC{I 0X' , ej SY1 C�COUNTY Tndaa(- \Upf <br />ZIP CODE: BUSINESS PHONE: %�J o131Sj <br />I <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />rw1Uvow 1 <br />3. MANAGER'S NAME-.R\MC1f C'\ NC-W�\ I \� WCk(T <br />ADDRESA: LDJ M. .G 10-Mao::&P� 3)Ye,�, Q qb3 <br />PHONE #: D-7� <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME <br />04 <br />ADDRESS <br />POSITION <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAM E <br />ADDRESS <br />PHONE # <br />U,\Beth\Beth Casano EOMCOPCMRENEWAL PACKETS\COPCN Application.doc 2 77 <br />