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This form must be completed for all new facilities and for any changes to facility information (Type or Print in Block Letters)Facility Information (as it will show on permit)Phone:Name: Fax: Facility
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This form is a tax form.
Individuals and businesses meeting certain criteria are required to file this form.
This form must be filled out accurately and completely with all relevant information.
The purpose of this form is to report income and expenses for tax purposes.
Income, expenses, deductions, and credits must be reported on this form.
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