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FACILITY IDENTIFICATION
1. Name of Applicant: _______________________________________________ Date:

Name of Property owner(s) (if different from Applicant):

2. Name of Firm or Facility:

3. Mailing address:

City: __________________________________________ State:________________ Zip:

4. Facility address (if different):

City: __________________________________________ State:________________ Zip:

5. Business Telephone No.:___________________________ Home Telephone No.:

Cellular Telephone No.:____________________________ Fax No.:

E-Mail address:
Applicant hereby makes application to the Kansas Department of Health and Environment in conformance with K.S.A. 65-171d et seq. and K.A.R. 28-18-1 through 17, and/or 28-18a-1 through 33.