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` 'ATION OF RESTROOM FACILITY <br /> lase provide all information reques, <br /> VEIUCLE INFORMATION s. <br /> Vehicle Name (DBA): L �p SAC CZ p\ <br /> Address for Vehicle: 7 SO S Cly,U _o(2 l P, ST S`Cc�cK` 0l-A CA <br /> Street Address City Zip <br /> 1) License Plate#: 70'30(,Q'2 4) 'rear: <br /> 2) Vehicle Vin#: 5) Make/Model: CfAWV <br /> 3) State Decal#: M Color: QICK 1G01 1 <br /> VEHICLE+Q«'NER INFOR111ATIQJ%�, � .���� <br /> Name: Uf„�P,�IaI� �HLF_Z <br /> Address of Owner: Q6- A00 wf,,y oi k (tA ..�Ok3siL (Lp` A53c t <br /> Street Address City Zip <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand <br /> washing facilities. This is to ensure restroom facilities are available to employees whenever the mobile <br /> food facility is stopped to conduct business (CalCode section 114315). <br /> I have access to the restroom facilities at the following business during my business hours and I am <br /> parked ess than 200 eet away from the restroom facilities. I will be responsible for maintaining the <br /> restro in a clean d sa ' ry condition. <br /> t5_ 2020 <br /> Si at re drVehide 06cratoP Date <br /> Oil <br /> la ROOM INFOIZ117ATION <br /> Business Name: (;1 (� Q ►M R 1�� <br /> Owner Name: <br /> Site Address: ik M L-lam- a"lt-U"S� 1S1 C94=16 1_1G( S `�C'h <br /> Street Address City Zip <br /> Phone: YF( -- 2-1 <br /> I, the business owner/operator, can and will provide the necessary restroom facilities for the operators of <br /> the above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health Department inspection. <br /> _ C) k- k5- 9- 6 <br /> Signature Business owner/Operator Date <br /> RECEIVED <br /> JAN 16 2020 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT!SERVICES <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />