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VERIFICATOuN OF VEHICLE COMMISSARY <br /> Please pravlaieail Wornmeon mqueeted. An?noompleja application may delay approval. . <br /> 1�1e€-v�i �9 �t26Ut, ef01 _ . . <br /> MAddress <br /> tfor <br /> (DBA); <br /> hicles AfPx <br /> sieaat aNs OI(p <br /> 4) Year. ,oz <br /> q/to <br /> ! 2) Vetiiote Vin� �/y�j'u/U�c�GSDy�Da � M��odel: <br /> 3) stab Decal _ p f} � 6) Color. <br /> �9iaE42BC6�' <br /> Name: J61AL-IY2 , 0,0 <br /> J Rddrass own@r <br /> staaaaAddass o�03 Gf9 Safi <br /> i oft <br /> t 'tie mobile t;-ood Pao?liiy shall aped out of a commissaw and shell mportto t ho co ° <br /> e{aorating day for demning and a®nvicing (Qdg@d®MCNOne 494ptld 914207), if ftae�am camnb aj is <br /> 1 disccyrLlna",the A�+it holder seas@ III MIS 6101120 to make the tnecessapg ohaaages. Failure to nol3[jj pais <br /> oPPice nay MUltin pante revocation and perra?t?es. <br /> iigrIII cure; 1:11:pVpepipclla{0 ator®�egr� p� paw <br /> .lt.C-�iUO3tlt'GY86Z•d1h-lliVE®CWV1E8 ®C6'�. sem e <br /> k Business Name: 1 �iti <br /> .. ,� <br /> ! site AcMass: 9f(}0 Linn r�i nG � a <br /> I sueatadd,aas tS C' n C ±620 h E <br /> Phone:(ZC-) L-1L, <br /> ` F <br /> €OMM'ssaEY owner,can and All provide the nec <br /> Gammisseq as chadwa below: ar fasditles frar the aYaove av rationed vehicle at env <br /> '*f Liquid @ solid weave Rose) R Ulsns,T wadit sink <br /> e2orsommmVII a�IlivEanilAd VehlClewashilidits a <br /> ❑PreAaratien of toad Hot&cold water for cleafta ©Toast&hand washing Q Store eefrigereted fAAd <br /> ❑ re fdry fnodlsuPp�es Pmvide polabie wa'rer Ovem ht <br /> �8 p at• <br /> �9 Ada"ftelectrical6uiieFs <br /> 5i naLvreofooDal>3 <br /> i Ornmel9 Dais <br /> q <br /> A— <br /> .. . <br /> Tow. <br /> i°the coramessery?tood ostahi?sharaent is ooa3tdde saa.ioaquin County,Me?Goal hadthjud ed?ation mast versy <br /> county.Y eadth pw-C&by sign'%below- :.0nBiissaryR*od esbMishment is in <br /> l <br /> Goun6y. - <br /> , <br /> Signature of County wre Date <br /> aD ts-an sofa <br /> tarmoa IMMAPPLICAnoR <br />