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CITY OF SANTA ARIA <br />BUSINESS TAX SECTION ` <br />20CIVIG CENTFR PLAZA, FIRST FLOOR (M-15), P.O, BOR 1964, SANTA ANA, CA 92702(714)647-5447 <br />COMMERCIAL CANNABIS <br />BUSINESS LICENSE TAX APPLICATION <br />(PLEASE TYPE OR PRINT CLEARLY, USING BLACK INX) <br />AFFIDA UT — CON ORATXAL (NOM' We erre unable to .process an incomplete application. Please complete this application and submit withyour <br />payment,) Post Office boxes will not be accepted for either Business or Residential addresses. <br />Corporation <br />(P.O. <br />Anit Business Start Aute j I"� `,(_2.0` 1 j <br />Pltpne ( ,� ) fL_j <br />Mailing Address (Irtrim ent) <br />03 ._ Emergeney Phone (V d <br />Enter in Fall CDTFA Seller's Permit # [ _ _ _ _ _ _ _ - _ _ I (W Brach Seller's Permit Copyi <br />A7,5Zr SubNbr <br />Ownership Of Business: 0 Consumer Cooperative Corporation 0 Agricultural Cooperative Corporation 0 Mutual Benefit Corporation <br />0 Corporation C t.imlted Liability Company (LLC) 0 {Prober (Describe) _._. <br />BUSINESS OWNER INFORMATION: Enter Sr, Corporate Ctfcersl Managing Members or Others (Describe) below— Use Add'1 Sheets as Necessary <br />Officer NamelNlernber;_� l ......_.._� Title 0144070 P- <br />Hame orr Corporate Address_ o) iy _. t tl� iw <br />License No, t 3, 9 � <br />Officer NamelMember �f?.g vat 1�:C v 2C_k_'jA _ Tisle _ gC �1 cur SSN # <br />Hemelor Corporate Address �� W O <br />CItS'�..T�":�e>�........ c• ".�..�.._.�._ StateZip � `�()�J Urlr:ens License Net, � Z.3`� t4�"�, <br />jzEEaE'WX= It:hae it ir. onthataplie t this A e ata u�v io a t r ' o et mm at t ss esti 'e <br />0 Commercial Cannabis Cultivator 0 Commercial Cannabis Distributor 0 Commercial Cannabis Manufacturer Ei Commercial Cannabis Retailer (Medical) <br />0 Commercial Cannabis Retailer (Adult -Use) ;K Commercial Cannabis Testing Laboratory <br />Description of Busimiss Activittyt <br />(To prevent a delay to Processing your applicedon, a description of bustneas oativi€ies and, where applicable, a description of itemSsold irmst be entered on the line above) <br />