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Get APPLICATION FOR HEALTH&nbsp - Cdph Ca

Mation only and is not to be used for any other purpose. To report any other required changes, please contact your local district office to obtain the appropriate forms. A. CURRENT FACILITY INFORMATION 1. Facility Name: 2. Type of Facility: 3. Current Street Address: City/State/Zip: 4. Days and Hours of Operation: B. LICENSEE INFORMATION 1. Licensee Name: License Number: 2. Federal Employer s Tax ID Number: 3. Licensee Street Address: City/State/Zip: 4. Telephone Number: 5. Fax Number: 6. E.

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