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11. COMPANY DETAILS <br />1., NAME OF AGENCY: *Wc-%e'T,(0vvN50o/ <br />MAILING ADDRESS: TY3 (S U j S e l uj �H 2?y <br />CITY I "�pt �I�- COUNTY 1�1' Lt!'G✓✓L <br />ZIP CODE: _ Zzi D ( BUSINESS PHONE: U <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): 1 <br />ert 04-1 ` <br />3. MANAGER'S NAME: LUIJ bav='v ,V5 <br />ADDRESS: 61 C j :H + 6i �t i US a . ( 6�✓1t- - <br />PHONE M Z (' 7 7 5- <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 />L/0 <br />ok+� D <br />S. <br />NAME <br />ADDRESS <br />9�)6t,1P,( <br />r. <br />POSITION <br />1�c4��tti. V1ce AeS <br />PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />&�c Ve v <br />ADDRESS <br />PHONE # <br />7 Z 1157a 7.1z53-2 <br />Z --5-6 "-S%C)?-- <br />�Tr lbN 5 Y <br />UABeth\Beth Casano EOC%COPCNIRENEWAL PACKETSICOPCN Application.doc <br />2 <br />,� <br />