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10/1e/2017 05:57 9168758588 PAGE 02/02 <br /> Oct. M 2017 9: 15AM No, 2463 P. 2 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An ihr.omplete application may delay approval. <br /> Vehicle Name(DBA); Agh and 0H <br /> Address for vehicle: 1100 Rfrhards Blvd Sacramento <br /> Stnatklem" City ' <br /> 1) License Pubs 9: 4NZ1494 4) Year: 2017 <br /> 2) Vehiclo Vin 0: GA1163647 5) MakafModsl; SANS VAN i(,TriI1e0 <br /> 3) stats decal o, N/A 6) Color: Cream giin'd Oteen wrap <br /> kY-,-(-)�C-N �Rr <br /> 10,M W�, <br /> N M-��ZF,11-22, <br /> Name; Venice Labra <br /> Address of 0wrior: 33161 St. H! Mands <br /> afloat Address City <br /> TIVO mobtle loco facility shall opamns out ofkcOmmlapary and shall report th the oomin',gsary <br /> operating day for Meaning and servIdIng (calCode suctions 144295 &114297). If the use of-ibe.comminamV is <br /> disoontlnuo,,Zu parmit lTr)idgr mug notify this of(Pne to make the neces4oryr rhartatta. Failure to notify this <br /> offf esult in permit revocation and Pgrialtien. <br /> nature of Vehirla O erator <br /> .6 <br /> 6uelness Name: <br /> NMI` eme., <br /> Site dress: <br /> Phones <br /> 611 ) el".- A 196ft My <br /> 1,thp commissary owner,can and wTjj provide the n ot pma ry r2o I 110W for the above mentioned-vehicle at my <br /> commissary nschocked beIbw-. <br /> 10�flquld&volld waste dfspannl�Erul-nzj washing str* <br /> 2-90M hnn tam 2V6hfee W$t;h ra"'d <br /> repatadon of food QHof 11trAdmiarforrianing [2-fdieja hand vaghirtu 01Stops Wrloerafgdfood <br /> Mara dry roodkupplies L�-Orz�ids 0oj&fa Wafer hL parking 4i <br /> M.of o� <br /> ftawre of ommis5a 0 nl9tlo cralai Date, <br /> ''r?R, <br /> E� <br /> v� <br /> If the Ctinlinlesaly/Food establishment Is oafsldtl Sen Jcaqlfln County,the loyal health Jurisdiction must verily. <br /> current health PP I b Igning below. Commissary/food ests6natiment is in <br /> ocun <br /> — _,_YIIZL—�� 7--C-il— lot Ila <br /> 50flattira of County REHS Dat6 <br /> EHD 16-D17 <br /> Received Time Oct. 18. 2017 9 :48AM No. 2467 <br />