2. Business Name*
4. Street Number*
5. Street Name*
6. Street Type
7. Apt #
9. City*
10. State*
11. Zip*
13. Business Telephone*
14. Type of Business*
16. Are there any hazardous materials stored at the business?*
    -- Select One --YesNo
17. If yes, what materials do you have and where are they stored at?
19. Location of electrical, water, and emergency shutoffs.
21. Does your business have an Emergency Evacuation Plan?*
    -- Select One --YesNo
22. Number of employees*
24. In the event of a natural or manmade disaster, does your business have any equipment or materials that could help out emergency personnel or the public?*
    -- Select One --YesNo
25. If yes, please provide a list of equipment and materials (I.E. Dump truck, bulldozer, oil dry, etc.)
27. Emergency Contact Name(s) with phone numbers(s)*
29. All the information provided will be kept confidential and stored in a secured computer system. This information will not be given to the general public, and will be used in the event of an emergency situation.

    1. I agree.
31. Name of person supplying the information provided*
32. Date*
    Date
34. Is this a New or Updated Registration?*
    -- Select One --NewUpdated
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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