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<br />.; --~ .. ..' <br /> <br />leb Bush <br />Governor <br /> <br /> <br />John O. Agwunobi, M.D., M.B.A. <br />; .~.:. Secretary <br /> <br />.... <br /> <br />.... <br /> <br />TEMPORARY EVENT SANITATION APPUCA TION <br /> <br />~ <br /> <br />This form is to be completed and taken to: <br />Pasco County Health Department <br />Environmental Health Services <br /> <br />7623 little road <br />New Port Richey. Fl34654 <br />(727) 841-4221 . <br /> <br />4135 land 0' lakes Blvd <br />land O'lakes. Fl 34639 <br />(813) 558-5182 ext 101 <br /> <br />139411S1t1 St <br />Dade City, Fl3352S <br />(352) 521-1450 ext 371 <br /> <br />~/V:&-I~/ ~( /l}g /)'1.1 re.~ .;) /,~I <br />fA-4 ieI'II p, BJ" ~ s' i:, <.. Cd '/ . r= 2"';0),/" "'It <br />~?q /1 0 So f) -1-.( f) / t.-" tt. I.' V <br />~ I .3. 7 ~ L'J - CJ 0 (, -) <br />2t::: 1JA-11;fl !f/!Is ;)--' /1')1- lilY! v -' t(J t./ IJt <br />I / ~ <br /> <br />~'DD <br /> <br />S A-f tJ{ cl J<}-I.-', f2 12-- G g ~ / / ,L) fl1 -;J fJ,n <br />/ i ,LlL~( <br />8. T oHet service provided by: .3 me"" . 3 LL~ E!:L, I ." ,.0, . iL " (!, y!, '1 <br />9. Dumpst~~~{k~~~~~~~~~:6~~red) [OCR.. 0 F '27: pI "112 ~,J c. <br />copy of contract required) I \ / <br />10. Handwashing sinks provided by: 0 l\) <>c~ p <br />~y at contract required) <br /> <br />The above (1does ( ) does not comply with the requirements at the Sanitary Code Requirements <br /> <br />1. Name at Event: <br /> <br />2. Operator/ Contact Person <br /> <br />3. Mailing Address: <br /> <br />4. Telephone: <br /> <br />5. location of Event: <br /> <br />6. Expected Number at attendance: <br /> <br />7. Duration of Event (dates/times) <br /> <br />When this form is completed, fee paid and Pasco County Health Department has signed off. return to: <br /> <br />Lr:b ex! L/ e iJ. cJtr/ s <br />/, [UQ s Ie -I ,(3r U,1 SeA- cI c-- <br />,.. '. 1\'\.0 '3. 7 e ~( <br /> <br />Pasco County Government Complex <br />Development Review Division <br />7432 little Road <br />New Port Richey, Fl 34654 <br />(727) 847-8142 <br /> <br />cY , .Oe(-e r ~;; <br />(3fJc1)!A1ed. ..~/7 k~4s f1n <br />d(,,~ <br /> <br />If you require any additional informatibn. please contact our office. <br /> <br />\ .l / r;/, ~ j),,&~~L; . ~ &~'b,-- <br /> <br />;( ignature of Owner/Agent Pasco CHD Representative <br /> <br />/ . I 'f, {) .3 III 1/0 ~ <br />D~ D~ <br />,6'60.00 <br />FEE:S5G:QO <br /> <br />Date Paid: f! t( h~ ;J <br /> <br />. Pasco County Health Department <br />Marc I. Yacht, M.D., M.P.H. - Director <br />10841 Little Road · New Port Richey, FL 34654-2533 <br />(777) ~hC)--:;Qnn .C::lInrnm <;<;')_77..,,, <br /> <br />Reciept #N0 7 z. ? <br />