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VERIFICVION OF RESTROOM 1.CILITY <br /> PRIase provide all information requested. <br /> 'VEHICLE INFORMATION �s'.F. � �Z <br /> 4.1.., S <br /> Vehicle Name(DBA): <br /> Address for Vehicle': ) 5 u�L ✓� S <br /> Street Address City Zip <br /> 1) License Plate#: 4) Year: 19 ? <br /> 2) Vehicle Vin#: + C L� f '� LAS,5) Make/Model: c j {C- y' <br /> 3) State Decal#: 6) Color: Jr5,,, <br /> VEHICLE OWNER INFORMATION <br /> Name: © 0 a-, <br /> Address of Owner: 1 0 a y v, <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 /> /fit- r:,� �;I;7_c "'\ 0 l 1-_ <br /> Signature of Vehicle Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: a <br /> Street Address City Zip <br /> Phone: <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 /> Signature Business owner/Operator Date <br /> R" E C E I VEE`L"� <br /> LIAR 21 2015 <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />