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VERIF;C;41��PON 0c: VFHICI.E COMMISSARY <br />Mime's provide ell i. nil atiOn re-Vicst0d. Pn fncornPl ate app I ication may delay approval. <br />VEH GLE INFORMATION <br />Vehicle Name (DBA): <br />------------ <br />Address *r•i Vehicle. <br />Street Address Gity <br />1) License Plate <br />2) Vehicle Vin -4:-Z, 33 51 ',lake a k e r� 11 de 1: <br />3) State Decal <br />TL <br />VEHICLE OWNER INFORMATION <br />Name. <br />_N__1g41Vy <br />Address of' <br />City <br />The moble foorlf.--illty shall cPrrate�nt F C.=1,lfssary a,j sham re-crttothe commissary at least once each <br />operating day for cieaning and Servicing C?!Code scctions 114296 & 1142971 if the use of the commissary is <br />discrritinue4 the permit holler mr-1 riiVfv 11 -c, make, the necessary changes, Failure 'to noflfv this <br />office may result in permit revocation and penalties. <br />Signature cs'iehic!euperaior -- ^ate I, <br />COMMISSARY INFORMATION <br />21-lsinessIvan -,& J <br />0\,,,ner Name <br />ILI <br />Site Address <br />AN <br />Street Address City --- <br />P --- —1 <br />Phone: <br />1. the com missary owner. can and u✓ill providr the n s-essan, facilities for the above mentioned vehicle at my <br />commissary as checked below: i <br />_lLou;" <br />z7= <br />Signature cf Ccm.mjssary <br />HEALTH DEPARTMENT <br />If thecommissary/food estabilsnment isriutsirl�a rUr-tv th i-,—1 health iurisdictic-, r.!.'st varfy i <br />current he2fth permit by signing beio,,v <br />coumy. <br />�'tQllai'J'e 0T Countv RENS Data <br />Ertl) �6-r MF7 4� �j <br />