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Ate 1. Type or print legibly. 2. Submit in duplicate. Include payment 3. Application must be received by our office 90 days (3 months) before permit expires. 4. Do not complete shaded areas. Issue date New expiration date STEP 1. GENERAL INFORMATION Name of applicant as printed on existing permit Permit Number Name of Business (d/b/a) State Tax I.D. number Business Address (number and street, city, state, ZIP code ) Business Telephone Area / Number ( Permit Type Release date Permit e.

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