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VERMC t, THOM OF VEMC LE CCO�i�ii��MISSAWY <br /> Please O rovide all infflrmarion requested. An incarcp><eite 6pplication may delay approval. <br /> Vehicie I14ame(DBA): <br /> Address for Vehicle: Z��d _ G - <br /> r! <br /> f Str22$AddP� vii <br /> 1) LicansePlate*: ( 41714 y 3 e-/ 7 4) Year. �Q <br /> 4 <br /> %) Vehicle Vin 9_ S) Make/Model: <br /> r v pp e > <br /> 3) State Decal#: 6) Color: [ /� <br /> e r, <br /> Name: <br /> S <br /> Address of Owner: <br /> S4restAddress <br /> lze i fob!Ie feoe facilI!t,j s['16il 0_Jer2i a Out 072 GOMriftsal?i and shaII rep `��s��e cfl�sfWasary a Gas once each <br /> ci47C} day fflr dieaning cind SeMois'a �ElCade sev ons '1114205 `' " • r r. <br /> s4��2g. is �e use of`tae c0sIroissery is <br /> i disc0n�ic� ed, �€�� pe Ei hoider �csk"10 i cap dais orrice to make,"lae necesawy cfanges. Failure to rant t-1-ais K <br /> 5 ffice 5`MaY rest/-K-:r1?7_e6itrev€ ca-dor:Pa.rid penalUes. <br /> t <br /> �l—Q 7 <br /> Signat`re of Vehic a Operator ©ate <br /> Business Name: Nr ; <br /> _I <br /> Ck <br /> s Owner Name: <br /> � <br /> Site Address. _Street A dr2SS r �J !tL+1t 1.ill �' r 1 c'• <br /> Phone: ] ct <br /> f ^ 3 <br /> £,.ire Commissary c3issary owner,CcS,and wfli provide necess3�f 1-201$>Iss for the above mcm.ganead v9hicig cZi s��i <br /> corarmissa€lf as checked bei0w: i; <br /> Q Liquid c solid waste disposal '" Utensil+nrasiling sink Store cozen food �� <br /> (2 or3compar3mens) o Q Vehicle t,a_h facilijes <br /> s ❑ Preparation o;food Hot&cold water f-or cleaning " Toilet&hand vLashin l <br /> g Q Store refrigerates food <br /> St a dry foodlsupplies Provide potable water ?a Ovemight parking Adequate electrical oistie <br /> ts <br /> 3 Signature of Commis ant Owner/Op pate t <br /> i tr e cc:mriss6F;11 cod est-ablielksment=s OUE e m joagtain Countj,the 1006$heal-Hijuelediedon mustve�:�f <br /> Curran'.hemith pen-nit 31r Signing- e <br /> a � ..�,� Ion;. commrssalllRo©d esicalsliishmbleni MIR <br /> Signature o,Counity REHS <br /> Date <br /> EHo 16-0(7 <br /> 7118/2008 5 0f 6 MFFU APPLICATIOi\! <br /> •r. <br />