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r � <br /> (vl d - -- <br /> - 2 <br /> VEROFOC ATOOO N OF VE OCaLE COMMOSSA, Ry <br /> Please provide all inforination requesired. An incomplete application may delay a�spr®vas. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: y f' <br /> Street Address <br /> s <br /> i) License Plate V: Year: <br /> s � <br /> i ^) Vehicle Vin 5) [UalcelModei: <br /> 3) State Decali <br /> �-- G} Color: <br /> vale igaa- 0�: qtr= :9 � <br /> ,_ <br /> Name_ <br /> ��- <br /> Address of Owner: S�,3,p C r <br /> S4seeY Addsas `^�t1 3 <br /> s'he-mobile toad facilky shall operato out et a commissanr and shall raport toane Com aaissarir at Peas=once easSZ <br /> j Operating day for cieaning and servicing (CalGcde seci-ions 9I4295 0 3942921'. lr the nese e,I6as cornmissartf is <br /> i discont,nueti, 417G ,15eMit hoider m,ust notify 12his of£ieee to make the necassaP91 chareges. Failure to raatity phis <br /> i Office May 'perrr=slt reviocaeior-and penalties. <br /> F <br /> i <br /> FSignacre of Vehicle Operator pa <br /> Business Name: <br /> r 3 <br /> r Owner f\Pane: C^)_ 1 . n m <br /> Site Address. <br /> �iSC�.iC1Cz i�.`:ib�; 3 6C' t:ill s� CI n- <br /> 2uh <br /> Sc"r2e�Address CRY <br /> Phone: (201) L! <br /> J <br /> R ` <br /> coammissa37f owner,can and Wili p¢oVide the reU2SZ2nj eCi?al eS fo€'YS32 aboVe Mentioned VC' e at nav <br /> hiciS <br /> I con,711issary as Checked below: g <br /> i <br /> Liquid&solid Waste disposal �%' Utensil washing sink i <br /> {2 ora romrarerrts) , Store frozen food ).\ Vehicfe wash facilities <br /> Q Preparation of food Hot&cold water for cleaning Toilet hand washing Q Store refrigerated toed o <br /> Qr—� <br /> stod y fvodisupplies Provide potable treater Overnight parking <br /> Adequate electrical outlets <br /> IVj <br /> Signature of Commissa 0+nfnerl0 eraior Date <br /> y <br /> c0arr�3issaqr/e9d estsbftlsimant is auiside para.s©agUin i:,Ount+f,the ioca9 heai8a jueisd;c ion must ve tt <br /> c�ri-eri�i3eakh pe mix by signing below. I—OMMissar+,llfood estabiishment is <br /> � :ev: i3tif. <br /> c <br /> Signature of County RcHS Date. <br /> 'a <br /> EHD 16-017 Sof s <br /> 7118(2008 MFPU APPLICA710M <br />