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IVERIFJCA7�ON OF VFHf1�1-F CCOMMISSARY <br />Please provide =U 4,°c-rraflnn recjuested � I--- i — application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): <br />Address for Vehicle <br />Street Addness citi, <br />1) LicensePlate# 09-5 7 5,/ X4 <br />2) Vehicle 1/in # <br />3) State 'Decal -Qz�b <br />- 7-5:7 <br />VEHICLE OWNER INFORMATION <br />Name: 117 <br />Address of-Owrri -ER-L-P 10 4/ 77 _A14— <br />The mobile food facility cut o- and shall rec.crItc 'the corrimiSsary at least once each <br />onerating day for cleening anci servicir- (Ce!Ccde secljons 1,1,1429, & 1142971 11 the USP. of the commissary Is <br />d : <br />iscontinuelY. the ner-nit holder rr'fV o rnalic the necessary changes. Failure to notify this <br />office mayresult in permit revocction and ncnalfles. <br />Sionature of Vehicle Operator ila'e <br />CONINMISSARY INFORMATION' <br />BUSMS-Ss NiaFre: <br />JIF <br />owne, i� -ne: <br />Site Addie:a <br />Street Address cliv <br />Phore <br />-,--2-;Zl- <br />1, the corn.-Esqary ownerrag and vAll facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />e <br />,e vvaB! i -es I <br />r-f,jaerale7 fCj, <br />• <br />C%vner;0-1`-T-rf <br />HEALTH DEPARTMENT <br />ry lh-� haai'� u! isdiction m NN <br />If the commissar yilood estlnfis�rrr.-��7 List vprf, <br />current: h9eitin oe,mit by sl�!i;rlr, bek-^v F,P: fr,%,,d <br />County. <br />S gn atu, -- of Gr. u ritv RENS Date <br />