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<br />OPERATOR'S NAME ADDRESS <br /> <br />PHONE <br /> <br />LIST TWO (2) CHARACTER REFERENCES <br /> <br />NAME <br /> <br />ADDRESS <br /> <br />PHONE <br /> <br />HAS APPLICANT/OWNER HISIHER DESIGNEE EVER BEEN CONVICTED OE A <br />CRIME, OTHER THAN A TRAFFIC VIOLATION: <br /> <br />YES NO <br /> <br />IF YES, GIVE EXPLANATION ON A SEPARATE SHEET OF PAPER, INCLUDING <br />TIME, PLACE AND NATURE OF EACH CRIME OR OFFENSE AND DISPOSITION <br />THEREOF. <br /> <br />LIST ALL CREDITORS INVOLVED IN THE CONSTRUCTION AND <br />MAINTENANCE IN ANY WAY PROVIDING DEBT OF EQUITY FINANCING TO <br />SAID OPERATION: <br /> <br />LIST CORPORATE OR PARTNERSHIP TITLE, IF ANY <br /> <br />CORPORATE OR PARTNERSHIP ADDRESS: <br /> <br />LIST ALL OFFICERS, MANAGERS OR DIRECTORS, IF CORPORATION: <br /> <br />Page 11 of 12 <br />