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VERIFICA ION OF RESTROOM ACILITY <br /> Please provide all information requested. <br /> .VtEC :E I rOR1VI~A. :. ,;"s <br /> Vehicle Name(DBA): IT <br /> Address for Vehicle: ��� <br /> Street Address City Zip <br /> 1) License Plate#: 1; 4) Year: 9 <br /> 2) Vehicle Vin#: 5) Make/Model: C =t}if V <br /> 3) State Decal#: 6) Color: +I � Y U-Z <br /> VEHICLE OWNER INFORMATION <br /> Name: t <br /> �7—c \ ' r <br /> Address of Owner: 1 1 <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 /> '�Lr r-e-S�' ' �I <br /> Signature of Vehicle Qperator Date <br /> RESTROOM INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: — S <br /> Street Address city V Zip <br /> Phone:`9 — LlLvlo <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 /> 40N�c A Q <br /> Signature Business owne erator Date <br /> RECEIVED <br /> MAR Z 1 2919 <br /> ENVIRONMENTAL HEALTH <br /> PE_R,'XT/SERVCES <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />