Service Request Form
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1919 856-7400
Tel
919 743-4772
Fax
ENVIRONMENTAL
Environmental Health & Safety Division
SERVICES
336 Fayetteville St. • PO Box 550 • Raleigh, NC 27602
Service Request Form
(This form must be completed and faxed in to 919-743-4772 for each request)
PLEASE PRINT
(
)
When applying for a food service or lodging operations permit, please note that pursuant to NC General Statute 130A-248, it is
unlawful to operate any food service or lodging facility without a permit. Permits are non-transferable and are required for
any new owner or lessee.
Service Requested: (CHECK ONE)
Type of Facility: (CHECK ONE)
_____ Construction Evaluation (CER)
_____ Restaurant/Foodstand
_____ Final Inspection (CEF)
_____ Mobile Food Unit**
_____ Equipment Evaluation only (EE)
_____ Pushcart**
_____ Field Consultation (FC)
_____ Lodging
_____ Office Consultation (OC)
_____ Child Care Center
_____ Other, please describe _________________
_____ Other, please describe ____________
**If request is for a Mobile Food Unit or Pushcart Evaluation, this form
and the Commissary Form must be faxed in together.**
Facility/Unit Information:
Facility Name:
**If request is for mobile food unit/pushcart, use commissary address.**
Physical Address:
Street: ____________________________________________________________
City: ________________________________ Zip: _________________________
Water Supply:
Municipal ______
Private Well _______
Waste Disposal:
Municipal ______
Septic System ________
Contact Information:
Name:
Address:
City: _______________________________ Zip: ___________________________
Telephone: (_____) ____________________ E-mail: ______________________________________
Alternate telephone: (_____) _________________________________
Signature of Applicant: _____________________________________
Date: ___________________
(Office Use Only)
Date Received:
Initials: ______ Permit #F
Commissary Form Forwarded To:
EHS Name
Date
S:\EH&S\FSS\Forms\Service Request Form.doc (Rev. 3-11/10/08)
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