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Account# CITY OF STOCKTON <br /> Customer ID# ADMINISTRATIVE SERVICES DEPARTMENT <br /> REVENUE SERVICES DIVISION—BUSINESS LICENSE TAX 425 <br /> License Ref# North EI Dorado Street• PO Box 1570 • Stockton, CA•95201 <br /> Phone (209) 937-8313 <br /> Email: bl@stocktonca.gov <br /> www.stocktonca.gov <br /> Declaration of Closure of Business In The City of Stockton <br /> y eP � hereby declare as follows <br /> I, <br /> Pri t Owner's ull Name l <br /> Business Name (DBA) <br /> Located <br /> at: <br /> Business Address, City, State, and Zip Code <br /> The business activity was: <br /> The final business date operating in the City of Stockton <br /> Mont /Day/Year <br /> I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE INFORMATION PROVIDED ON <br /> THIS FORM IS TRUE AND CORRECT. <br /> Title Date igned <br /> ner o Auth <br /> Home Address, City, State, and Zip Code <br /> Mailing&ess, City, state, and Zip Code, (If Different han Abo ) <br /> yo� 5q ' <br /> Phone Number <br /> BELOW THIS LINE FOR OFFICE USE ONLY <br /> -------------- <br /> Signature of Staff Person Inactivating Business License <br /> Date <br /> Date <br /> Revenue Supervisor Signature <br /> Pt� O5 22 SOS <br />