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VERIFICATION OF VEHICLE COMMISSARY <br /> 'EHICLE INFORMATION: <br /> ehicle DBA: <br /> ,ddress listed for Vehicle: E 7�InGl"Y1ll1lc/ <br /> icense Plate* 956 1�.L3 Veh. ID#:SPL 3512%704k"tate Decal#: <br /> 'ear: Make: Model_Color: 6 1,- Pp <br /> /EHICLE OWNER INFORMATION: <br /> Jame: Z <br /> IrtrL 31G5 it - CDL#: <br /> \ddress: 820 1"d L.'a r�rr)!A 'A o CrnZ�a City: Cj C IJ CA Zip Code: c 7 <br /> rHE ABOVE MENTIONED VEHICLE SHALL OPERATE OUT OF A COMMISSARY AND SHALL REPORT TO <br /> rHE COMMISSARY AT LEAST ONCE EACH OPERATING DAY FOR CLEANING AND SERVICING ICURFFL <br /> 114265 & 114287]. IF THE USE OF THE COMMISSARY IS DISCONTINUED THE PERMIT-HOLDER MUST <br /> NOTIFY THIS OFFICE TO MAKE THE NECESSARY CHANGES. FAILURE TO NOTIFY THIS OFFICE WILL <br /> INVALIDATE PERMIT AND IS SUBJECT TO PENALTIES. 1 <br /> /1 G � 3 i ,•! i `' , <br /> "`SIGNATURE OF VEHICLE OPERATOR DATE <br /> COMMISSARY INFORMATION: <br /> Business Name: -166M;Ssary L SfH./ <br /> Owner's Name: 'Yatitu Odra&. <br /> Site Address: City: Los, Zip Code: gSZyo <br /> Phone Number: ( 201 ) 75'1 -7476 <br /> I,THE COMMISSARY OWNER, CAN AND WILL PROVIDE THE NECESSARY FACILITIES FOR THE ABOVE . <br /> MENTIONED VEHICLE AT MY CO"ISSARY AS CHECKED BELOW: <br /> Er Preparation of food Er Store Frozen Food W Store Refrigerated Food <br /> Electrical Hook-up G- Store Dry Food nz'$tore Supplies <br /> m' Toilet Handwashing vemight parking [!t/ Supply Food Products <br /> ia?, 'Gt4 ' f2-j-2o <br /> SIG14ATURE OF COMMISSARY OWNER/OPERATOR DATE <br />