Are you an existing client of Allen Stahl + Kilbourne?
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Your Name
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First Name
Last Name
Phone Number
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best # to contact you right now
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Establishment Name
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Establishment Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Establishment Phone Number
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(###)
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Email
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Water source will be:
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check all that apply
Boiled Water Storage containers:
Source of Ice
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Transport and storage containers for ice
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A handwashing setup is required with a gravity flow handwashing container with a continuous flow spigot and a catch basin (if equipment allows, let water drain into existing sink). How many handwashing set-ups will be used?
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Describe handwashing setup:
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A contingency plan is required for flushing toilets. Describe the process for flushing toilets using alternate water supply OR indicate that a porta potty will be provided.
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Mechanical warewashing machines and chemical dispensers cannot be used. Sanitizer at proper concentration must be mixed in three compartment sink and utensils must be washed, rinsed and sanitized using the sink. Describe the cleaning and sanitizing process, and state what sanitizer will be used and how it will be mixed:
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Only single service eating and drinking utensils will be used.
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Catch basins for sinks will be emptied into sanitary sewer using a can wash, mop sink, toilet, or other operational drain.
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Any food or ice prepared using unapproved water source will be discarded.
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If safe alternate water source is exhausted, facility will close.
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Water using fixtures that have unapproved water source have been turned off with signs posted that water fixtures cannot be used. This includes sinks, ice machines, warewashing machines, beverage dispensers, etc.
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Additional Information
Thank you for completing this form. This will help us prepare your Emergency Water Supply Plan form for submission to the Buncombe County Department of Health and Human Services, Division of Environmental Health.
Don’t forget to email your limited/simplified menu to cheiser@asklawnc.com as soon as possible.
Someone from our office will email you within 24 hours with your completed form for you to electronically sign before we submit it to the Buncombe County Department of Health and Human Services, Division of Environmental Health for approval.