Spreadsheet: 09d54627-3c49-465d-a8a9-1cfb502ab491
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | Unnamed: 28 | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | Unnamed: 38 | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42 | Unnamed: 43 | Unnamed: 44 | Unnamed: 45 | Unnamed: 46 | Unnamed: 47 | Unnamed: 48 | Unnamed: 49 | Unnamed: 50 | Unnamed: 51 | Unnamed: 52 | Unnamed: 53
 | CHANGE OF OWNERSHIP/Data Entry FORM
 | ¿Ha tenido algún permiso [NAME] otorgado por Salud Ambiental en el pasado? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Si |  |  |  |  |  |  |  |  |  | No
 |  |  |  |  |  |  |  |  |  |  |  | Nombre |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Inicial |  |  |  |  |  |  |  |  | Apellido
 | Dirección del Dueño - > |  |  |  |  |  |  |  |  |  |  | Dirección
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]: |  |  |  |  | (                   ) |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | [NAME]:
 | Dirección de Correo |  |  |  |  |  |  |  |  |  |  | Calle o PO Box
 |  |  |  |  |  |  |  |  |  |  |  | Attn:
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 |  |  |  |  |  |  |  |  |  |  |  | Nombre |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Inicial |  |  |  |  |  |  |  |  | Apellido
 | [NAME] |  |  |  |  |  |  |  |  |  |  | Dirección
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]: |  |  |  |  | (                   ) |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | [NAME]:
 | Dirección de Correo |  |  |  |  |  |  |  |  |  |  | Calle o PO Box
 |  |  |  |  |  |  |  |  |  |  |  | Attn:
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 | Send Mail To: |  |  |  |  |  |  |  |  |  |  | Owner's Address |  |  |  |  |  |  |  |  |  |  |  |  | Facility Address |  |  |  |  |  |  |  |  |  |  | Other Address |  |  |  |  |  |  |  |  |  | (see next line)
 |  |  |  |  |  |  |  |  |  |  |  | Address |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | City |  |  |  |  |  |  |  |  |  |  |  | St |  |  |  |  | Zip
 |  | FACILTY INFORMATION
 | Nombre [NAME] |  |  |  |  |  |  |  |  |  |  |  | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Office Use: |  |  |  |  | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  |  | Nombre Nuevo |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Office Use: |  |  |  |  | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  | Dirección
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 |  |  |  |  |  |  |  |  |  |  |  | [NAME]: |  |  |  |  | (                   ) |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | Extension:
 | Dirección de Correo |  |  |  |  |  |  |  |  |  |  | Dirección
 |  |  |  |  |  |  |  |  |  |  |  | Ciudad |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Estado |  |  |  |  |  |  |  |  |  |  |  |  | Código Postal
 |  |  |  |  |  |  |  |  |  |  |  | A la Atención De:
 | Contactos - > |  |  |  |  |  |  |  |  |  |  | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] Secundario
 |  |  |  |  |  |  |  |  |  |  |  |  | Nombre |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Nombre
 |  |  |  |  |  |  |  |  |  |  |  |  | Titulo |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Titulo
 | Día |  |  |  |  |  |  |  |  |  |  | Phone No | Teléfono |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext |  |  |  |  |  | Teléfono |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext
 | Noche |  |  |  |  |  |  |  |  |  |  |  | Teléfono |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext |  |  |  |  |  | Teléfono |  |  |  | (         ) |  |  |  |  |  |  | - |  |  |  |  |  | Ext
 |  | [NAME]
 |  | ESTA PARTE SERA COMPLETADA POR EL INSPECTOR
 |  | If this form is not completely filled out, a permit cannot be issued.
 |  |  | What type of permit is this? Circle one: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Annual |  |  |  |  |  |  |  |  |  |  |  | 90 day interim
 |  |  | If permit is a 90 Interim permit:
 |  |  |  |  |  | Date permit is valid from:
 |  |  |  |  |  | Date permit is valid to:
 |  |  |  |  |  |  |  |  | Send invoice? Circle one: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | YES |  |  |  |  |  |  |  |  |  | NO
 |  |  |  |  |  |  |  |  | Program Identifier: |  |  |  |  |  |  |  |  | ________________________________
 |  | Remarks: |  |  |  |  | _______________________________________________________________________________________
 |  |  |  |  |  |  | _______________________________________________________________________________________
 | What PE's are needed:
 |  | PE __________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PE__________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PE_______________ |  |  |  |  |  |  |  |  |  |  |  |  | PE______________
 |  | PE___________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PE__________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PE_______________ |  |  |  |  |  |  |  |  |  |  |  |  | PE______________
 | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Firma del Inspector
 |  | O:General Resouces & Info/Forms/Data Input Sheet revised 11 04 2010.xls