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' `ERIFIC.' TION OF RESTROOM F XCILITY <br /> r,case provide all information requester <br /> VEHICLE INFORMATION <br /> . Vehicle Name(DBA): p(�S q <br /> - -- - <br /> Address for Vehicle: <br /> Street Address City Zip <br /> 1 <br /> 1) License Plate#: q � '4q q 4) Year: ab to <br /> 2) Vehicle Vin#: l l t V a C-_Rj� ) Make/Model: Nio,,oy N 1�l c <br /> 3) State Decal#: 'cfg 6) Color: <br /> VEHICLF, OWNER INFORMATION <br /> Name: r� <br /> Address of Owner: U <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 less than 200 feet away from the restroom`facilities. I will be responsible for maintaining the <br /> restroom in a clean and sanitary condition. <br /> _1m4r7C1 <br /> Signature of Vehicle Operator Dale <br /> 'RESTROOM INFORMATION <br /> Business Name: <br /> Owner Name: � , <br /> Site Address: <br /> �.�q Street Address City Zip <br /> Phone: (ZVJ l — s�� CQ 15 to <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 Departmen 'nspection. <br /> '_.o�� 2 _ /�-/- '120_ <br /> aturi r O <br /> siness o perator Date <br /> 'n 16-013 Page 9 of 9 MFF APPLICATION <br /> ,n� <br />