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VERIFICATIONOOF VEHICLE Oi.—,',OMMISSARY' <br /> ,01—se P,ovide 3!! <br /> incomplete, appic.,,-:tion rna.v ripIF-v a'JDpr( <br /> VEHICLE INFORMATION <br /> Vehicle Namie (DLOA). �41 ��a <br /> Address for Vehicle- Q� <br /> Street Address <br /> I) License Plate#. <br /> 2, Vehicle Vin ±t', <br /> 3) State Decai #* <br /> VEHICLE OWNER INFORMATION <br /> Name. <br /> Address ofjOwner: <br /> tree*.t A dd $s City <br /> The mcbi�e food facility shalloperate out- -4 ;� o r�, <br /> conim�tzsFry at 1—c-4. -e aac! <br /> operatfng day for cleaning and servicir- "29"', '11,1297:, If the use of the <br /> discontinued. the permn't hold&-, ,,I 4-he nPi7esSpr", ,Jhanges. <br /> ....... Fa'slure this t <br /> office may result in parmit revocatlo!- <br /> Signature of Vehicie O-perp-to:---- ate <br /> COMMISSARY INFORMATION <br /> Business Narre.&J, <br /> Owner Narne. v-c;' <br /> Site Address- <br /> Street Addrez-.s cit", <br /> Phone: (2ocy <br /> 1, the commissary owner. can and v,-HI crovir!,: -1.=cessarv'fs <br /> commissary as checked below: <br /> 0 zr.e� <br /> Signaiurefoll Clommissary Ovmer,arc 11' <br /> HEALTH DEPARTMENT <br /> if the cornimissary"food m ,Cz <br /> current heaith rermit by sigr.ing beicv., <br /> r, <br /> 1.0unty.. <br /> Signature Of COLIn-ly RE'-HS e <br /> L <br /> 7 C:" <br />