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II.. COMPANY DETAILS <br />1. NAME OF AGENCY: <br />MAILING ADDRESS: q9 -,U <br />CITY �4,\QcS�S COUNTY�tc;r�, <br />ZIP CODE: BUSINESS PHONE: <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />3. MANAGER'S NAME: ce co <br />ADDRESS: '%U \-k.npraL\tA-e. &4e <br />PHONE #: ecA - \oo <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 ADDRESS POSITION <br />mCa,� <br />�Va�c,.:> <br />ccs <br />C,��`��`'b\. <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />�u"�� �i�;Qt �(. i,�ec.�c.t' 851(,1. t,�}c Sl..s :�C.-i o •1 �y� �� �c�tc.e ; �\ e �- 3�.�1�4 C3�\> Flo v - io\\� <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 2 <br />79 <br />