Registration Application Form
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1REGISTRATION APPLICATION FORM
BILLING DEPT. (951) 955-3002
GENERAL INFO. (951) 955-3030
COUNTY OF RIVERSIDE
FAX (951) 276-4728
DIVISION OF WEIGHTS AND MEASURES
PO BOX 1089 RIVERSIDE, CA 92502
“Packer” or “Point of Sale” station locations
Section A
: ____________________________________________
: ___________________
Name of Business
Date
: _____________________________________
:_____________
:___________
Physical Address
City
Zip
: _______________________________
: ________________________
Location Contact Name
Phone
: ________________________________________
: __________________
Owner/Corp. Name
Phone
: _______________________________________
:______________
:___________
Billing Address
City
Zip
:_____________________________
:_____________________
Billing Department Contact Name
Phone
Corporation/LLC/LP registration number:______________State of Jurisdiction:______:Date of File:______
:____________________________________________
:___________________
Agent for Service
Phone
(Name of person in California authorized to accept service of process)
:_______________________________________Ci
:______________
:__________
Mailing Address
ty
Zip
(Address of person in California authorized to accept service of process)
: ____________________________
Number of Packages produced per year (if applicable)
: __________________________________
Number of Point of Sale Stations (if applicable)
Remarks: _____________________________________________________________________________________________
______________________________________________________________________________________________________
: ___________________________
: ________________________
Owner/Agent Signature
Print Name
To see County Ordinance 832 visit:
“PACKER” means any person engaged in wrapping or packaging of a commodity within the County of Riverside prior to and
for the purpose of sale wherein the item wrapped or packaged is sold on the basis of weight, count, volume or area.
“POINT OF SALE STATION” means individual and separate equipment that is capable of recovering electronically stored price
information used to charge consumers for the purchase of commodities. “Point of sale station” shall include, but is not limited
to, equipment that uses Universal Product Code scanners, price look-up codes, or any other system that relies on the retrieval of
electronically stored information to complete a transaction of commerce between a retailer and consumer.
FOR COUNTY USE ONLY
Section B
Permit Number: _____________________
Fee Amount: $ __________________
New ____ Change ____ OOB ____
Ord. # 832____
District: ______________
Info: _____________________________________________________________________________
Inspector: ______________________________________
Date: _______________
Form 102 (REV 4/30/12)
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