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2. Legal Business Name & DBA:*
4. County Permit Number:*

   If you do not yet have a county permit number you may enter N/A.

6. State License Number:*

   If you do not yet have a state license number you may enter N/A.

8. Business Type (select all that apply):

   1. Cultivation - Indoor
   2. Cultivation - Mixed Light Tier 2
   3. Cultivation - Outdoor
   4. Cultivation - Mixed Light Tier 1
   5. Nursery
   6. Retail - Storefront
   7. Retail - Non-Storefront
   8. Manufacturing
   9. Delivery
10. Business Physical Address:*
12. Business Mailing Address:*
14. Business Contact Person:*
16. Email:*
18. What section of regulations in Ordinance No. 2523 are you requesting relief from?*
20. Is this request related to COVID-19?*
22. Please explain why you need relief from this requirement:*
24. Full Name:*
26. Title:*
28. Supporting Documents:
30. Supporting Documents:
32. Confirmation:*

    1. I declare under penalty of perjury that the information contained in this form is true and correct and that I am signing as an authorized agent of the business listed on this form.

    I understand that storage of contact information, including but not limited to names, telephone numbers, and email addresses in the TTC's request database may constitute a public record that may be subject to disclosure under the California Public Records Act, Government Code Section 6250.

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field