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Get Clm And Clf Cdph Licenses Form

LM, CLR, CLP, COS) CLIA ID #: 05D Laboratory Name: Laboratory Address: City, State and Zip Code: Telephone Number: Fax Number: E-mail Address: Please mail completed form to: California Department of Public Health, Laboratory Field Services, ATT: Facilities st Licensing, 850 Marina Bay Parkway, Bldg P, 1 Floor, Richmond, California 94804-6403. THIS IS TO REQUEST CERTIFICATE CHANGE: THIS IS TO INFORM YOU OF A From: Change of ownership ( See note below ) TO:.

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