License Number: (numbers only in the following format: YYFFFNNNN where YY is the last two digits of the year the permit was issued, FFF is the three-digit county fips code, and NNNN is a sequential number such as 0001, 0002, etc.)

Establishment Name:

Owner Name:

Manager Name:

Address:

City:

Zip:

County: Dallas Polk

Latitude: (decimal degrees)

Longitude: (decimal degrees - remember, West is a negative number)

Phone Number:

Fax Number:

Priority: High Medium Low