City of Hodgenville, Kentucky

Company Name:

Owner Name:

Owner Phone Number:

Cell:

Facility Address:

City:

State:

Zip Code:

Facility Phone Number:

Type of Business:

FACILITY OPERATIONS:

Does your facility prepare or serve food?

What types of food is prepared or served?

Please explain which part(s) of the FOG Management Program this facility is requesting exemption from and explain in detail the reasoning/justification for this exemption request:

I certify that i am familiar with the information contained in this application and that to the best of my knowledge and believe that such is true, complete, and accurate.

Signature:

Sign here

Date:

Company Name: *

Owner Name: *

Owner Phone Number:

Cell: *

Facility Address: *

City: *

State: *

Zip Code: *

Facility Phone Number: *

Type of Business: *

Does your facility prepare or serve food? *

What types of food is prepared or served? *

Please explain which part(s) of the FOG Management Program this facility is requesting exemption from and explain in detail the reasoning/justification for this exemption request: *

Signature: *

Date: *