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Description of a Mobile Food Dispensing Unit i
Any food service establishment that is self propelled or otherwise moveable from place to place,"Ithat is
self contained and does not use electrical or other utility connections of any kind, in which food is
prepared and/or dispensed,and that complies with all applicable requirements set forth by the Florida
Department of Business Regulations,division of Hotels and Restaurants, or its successor agency;
including but not limited to those regulations set forth in Rule 7C-1.03,Florida Administrative Code.
Property Owner Information:
Name: l,�w&Wor,.A P SIL 74 LL.C' PhoneNo:
Address: M(o 3 -75' VA L-LdC 1e046 Sy-I r-1,- VO
city: Try State: - '� Gip Code:
Date:
I, owner of the following described property, authorize
�RU3bC-i n J t,K Los (. to place a mobile food/produce unit on my property.
x Property Tax Identification #: 3 l j- (0 1 - ® dD ® /
k Legal Description: .5%13gl /wr%t% 6k-I�n � C--rY `L.al�o J Q P*w-y1✓% - 11--A
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Property Owner's Name (Please Print) Property ner's ignature
State of Florida, County of
- ---- lie fQregoi:_b-inu .: :ssen*=ras acknowledged=before-me this- , day of JLOLI
who is personally known to me V'-or who has produced t341t121L-;,-j %Glllli�
as identification.
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F BARBARA C.CRUZ
�* (- .�;• MY COMMISSION#EE 832047
��° ' BondedlRES:September 17,2016 (Seal)'
ers
Signature of Notary Type or print Name o o a
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Title: Notary Public Commission Number: i
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SLCPDSRevised 07/21/2014 �q�>r>. �e�" BARBARA C.CRUZ
fv y COMMISSION#EE 832047
EXPIRES:September 17,2016
'oF;u�NfQ�' Bonded Thru Notary Public Underwriters
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