Environmental Health Permit Application Form - California Department Of Public Health
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1
2ENVIRONMENTAL HEALTH PERMIT APPLICATION FORM
Environmental Health Division of Public Health Services Department
661-862-8740
2700 “M” Street, Suite 300, Bakersfield, CA 93301
661-862-8701(fax)
New Business
Ownership Change
Date: __________
Information Change
Date: ___________
Type of Ownership:
Sole Proprietor
Partnership
Corporation
Other:________________________
Food Facility
Hotel/Motel: Total Number of Rooms _____
Mobile Food Facility
Swimming Pool
Commissary
Check all
Temporary Food Facility
Wading Pool
Water System-Food Facility
that apply:
Community Event Sponsor
Spa Pool
Tobacco Retailer: BOE#______________
OWNER INFORMATION
Owner Name:
Owner Address:
City:
State:
Zip:
(
)
(
)
:
Home Phone:
Business Phone:
Fax
Partner(s)/Corp
Name:
Care Of:
E-Mail Address:
Mailing Address:
City:
State:
Zip:
FACILITY/BUSINESS INFORMATION
Facility Name
(DBA):
Address:
City:
State:
Zip:
(
)
(
)
: (
)
Phone:
Alternate phone:
Fax
Care Of:
E-Mail Address:
Mailing Address:
City:
State:
Zip:
Water Provider
BILLING INFORMATION
Business Mailing Address
Owner Address
Other
Mailing Address for invoice to renew annual permit:
If you checked other, what is the address? _______________________________________________________________
Care of:__________________________________________________________________________________________
Approval of this application and issuance of an Environmental Health Permit is required before commencing operation. Failure
to obtain both may result in a misdemeanor citation and/or closure. The undersigned applicant agrees to operate in accordance
with all applicable state laws and local ordinances.
Signature of Applicant
Print Name
Date
PERMIT(S) AND FEE(S) ARE NOT TRANSFERABLE.
PERMIT FEE(S) MUST BE SUBMITTED WITH PERMIT APPLICATION.
TOBACCO RETAIL TRAINING
FOR OFFICIAL USE ONLY
Program ID
PE
Date Mailed
Facility ID
Previous Owner ID
New Owner ID
Map #
Service Request #
Total Fees Paid
Received By
Date Paid
Accounting ID
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