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Administrative Change Request Form

Permits are not transferable. If this is a new owner a new permit application is required. This form may only be used to correct an owner name and/or address or add a mailing address.

The owner name and address is the entity or sole proprietor that owns the establishment. Management Companies may not be listed as the owner.

The default mailing address is the Owner address. If the Owner address is not the preferred mailing address, one may be indicated using this form.

Business Information

Name of Permitted Establishment
Address City Zip
Permit #'s

Owner Information

Name of owner (permit holder)
Address City State Zip
Phone
Email

Mailing Information

Mailing Name
Address City State Zip
Phone
Email

Additional Contact Information

Additional Contact
Address City State Zip
Phone
Email

Environmental Health

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New Permit Fees

Permit types & scoring info

File a Complaint

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How is Our Customer Service?

Administrative Change Request Form

Business Information

Owner Information

Mailing Information

Additional Contact Information