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City of Blythe
235 N. Broadway
Blythe, CA 92225
(760) 922-6161

Business Name:*

DBA Name:

Physical Address:*

City:*

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Description of Business:

Home Based Business:*

Yes

No

Type of Ownership(Select One):*

Individual Partnership

Corporation Non-Profit

Owner Name:*

Owner Address:*

City:*

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Do you store Hazardous or Flammable Materials?

Yes

No

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