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NF-T-141CLE 177,10MMISSARY <br /> p! S v I I 1�, r� �;cr) --r 1 r in: ni?N application Mqy delay aPP :YV:�1. <br /> yr A <br /> VEHICLE INFORMATION <br /> Vehicle <br /> Add:ess <br /> Street-Address C;t.� <br /> 1 License Plate,#. "ear: <br /> \,,ehjc1e Vin +#4. 7-6—D-14-P-3-'� <br /> 3) State Deca! <br /> ------------ <br /> VEHICLE OWNER INFORMATION <br /> Name: I I <br /> L-A-n-s "- v(-v iix <br /> ss of 17);�'%'ner <br /> - -- - �- "5[ 61 VA <br /> F Tri rp C C v I --- - <br /> Street A,ddross <br /> -on— Pach <br /> The mobile food facility Shall operate out of _ commmssary an.d shall repo-t,,- '.-.a commissary at least <br /> Doerating dav f-r cleanirg and s=rvic'r.ri (C1-de ser-H <br /> r I - !� -o ris 114295 & 1,1429TI if the use of the cornni;ssary is <br /> dis,;ontinu�ed, 'he permit holder r-nust - to rn.;;k, the necessary changes, Faftlr'a to n-tilv this <br /> office may result in parmit revocation and <br /> Signature ofVehicie a Operato,-- n. e �AVq Date `0 a v <br /> COMMISSARY INFORMATION <br /> Pusiness Name: j <br /> �2r n I <br /> Owner Name.- C-1 ve-'ba <br /> -A <br /> Site Address- - I <br /> Street ;ddr;=5v, City <br /> Phone-. <br /> I vehiclea <br /> 1, the commissary owner, cart and will pry' 'he necessary facilities for the above mentioned Q Mw <br /> covnmlssary as checked below: <br /> va-ste e ^vl <br /> �� J^ n, z I 1 ,. _ ..l <br /> c ref -,er.+efj ff�(Dj <br /> '-4 q <br /> Signature of Commissary Owner/Operattor D-ate <br /> HEALTH DEPARTMENT <br /> if the cornmissanjifood establishment is outside San f-''ounty, the locail heatth jurisdiction must verify <br /> current health peri-nit by slgnhig belovv is In <br /> County. <br /> SignatUre of County REHS Date <br />