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Get California Department Public Health Address Change Form

State of California Health and Human Services Agency California Department of Public Health RON CHAPMAN MD MPH Director State Health Officer EDMUND G. BROWN JR. Governor Change of Address Form Please fully complete the following information and fax or mail it to this office. Do not e-mail it this form as we will only accept a change of address with a valid signature. Mail to CDPH-OCP MS 7417 P O Box 997377 Sacramento CA 95899-7377 Fax to 916-449-5654 Please Print All Information Below Name Distribution Treatment New Mailing Address City State Zip Work Phone Extension Cell Phone Home Phone E-mail address Signature/Date Division of Drinking Water and Environmental Management Drinking Water Program / Operator Certification Unit MS 7417 P. O. Box 997377 Sacramento CA 95899-7377 916 449-5611 or 449-5610 / Fax 916 449-5654 Internet Address http //www. Do not e-mail it this form as we will only accept a change of address with a valid signature. Mail to CDPH-OCP MS 7417 P O Box 997377 Sacramento CA 95899-7377 Fax to 916-449-5654 Please Print All Information Below Name Distribution Treatment New Mailing Address City State Zip Work Phone Extension Cell Phone Home Phone E-mail address Signature/Date Division of Drinking Water and Environmental Management Drinking Water Program / Operator Certification Unit MS 7417 P. O. Box 997377 Sacramento CA 95899-7377 916 449-5611 or 449-5610 / Fax 916 449-5654 Internet Address http //www.

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